Based on observation, interview, and record review the facility failed to ensure one of 19 sampled residents (Resident 38), was provided the necessary care to maintain good grooming and personal hygiene. This failure resulted in Resident 38 not receiving fingernail care and had the potential for infection and to negatively impact Resident 38's overall health. Findings: Review of Resident 38's face sheet indicated Resident 38 was admitted to the facility for multiple diagnoses that included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 38's Minimum Data Set (MDS, an assessment and care screening tool), dated 2/7/23, indicated Resident 38's cognitive skills (related to thinking, reasoning, decision-making, and problem solving) were severely impaired. The MDS indicated the resident was fully dependent on staff for dressing, eating, personal hygiene, and toilet use. During an observation in the resident dining/activities room on 3/4/24 at 10:35 a.m., Resident 38 sat in a wheelchair, Resident 38's fingers were noted to have brown/black substance under the nails of her right hand. During an observation in the resident dining/activities room on 3/6/24 at 2:04 p.m., Resident 38 sat in a wheelchair with a food tray. Resident 38's fingers were noted to have brown/black substance under the nails of her right hand. During an observation in Resident 38's room on 3/8/24 at 8:25 a.m., Resident 38 lay bed. Resident 38's fingers were noted to have a brown/black substance under the nails of her right hand. During an interview with Certified Nursing Assistant (CNA) D on 3/8/24 at 8:45 a.m., CNA D stated Resident 38's nails were dirty on the right hand. CNA D stated nails should be cleaned during every bath or shower. During an interview with Licensed Vocational Nurse (LVN) F on 3/8/24 at 9:38 a.m., LVN F stated nails should be nice and clean. Resident 38's shower days are Monday and Thursday during the evening (PM) shift and if the resident refused, the reason why should be documented. During an interview with the Nursing Supervisor (NS) on 3/8/24 at 10:08 a.m., the NS stated showers are documented in tasks including refusals and nail cleaning should be done during showers. During an interview with CNA G on 3/8/24 12:59 p.m., CNA G stated bed baths or partial baths, all include cleaning the hands and nails. CNA G stated Resident 38 is scheduled for PM shift; who do the total bath including the hair. During an interview in Resident 38's room with CNA D and CNA E on 3/8/24 at 2:34 p.m., CNA E stated, Resident 38's nails have been dirty all week and they should be cleaning the residents nails. During a review of the undated Resident shower schedule, the schedule indicated Resident 38 was scheduled for showers on PM shift on Mondays and Thursdays. During review of Resident 38's the task list, dated 3/2/24 thru 3/08/24, indicated Resident 38 received a bath/shower/bed bath 3/4/24 (Monday). There was no indication Resident 38 received a bath/shower/bed bath on 3/7/24 (Thursday) and there was no documented resident refusal. During a follow up interview with the NS on 3/8/24 at 2:56 p.m., the NS stated only scheduled days would be documented for showers. The NS confirmed Thursday 3/7/24 was a scheduled shower day that indicated NA, which meant a shower or bed bath was not given; and that, it should be documented if the resident refused. Review of the facility's policy and procedure titled, Care of Fingernails/Toenails, dated February 2023, indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . Nail care includes regular cleaning and regular trimming. Gently, remove the dirt from around and under each nail. Review of the facility's policy and procedure titled, Bathing/Showers, dated February 2023, indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Documentation . If the resident refused the shower.

Based on interview and record review, the facility failed to monitor the side effects related to the use of Apixaban (an anticoagulant [blood thinner] medication that interrupts the formation of blood clots) for one of 19 sampled residents (Residents 38). This failure had the potential to affect the residents' physical well-being while in the facility. Findings: During a review of Resident 38's Medical Record (MR), the MR indicated Resident 38 was admitted to the facility for multiple diagnoses that included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, and chronic atrial fabulation (an irregular and often very rapid heart rhythm). During a review of Resident 38's medical record, the physician orders, dated 1/6/23, indicated, Apixaban Tablet 5 milligrams (mg, a unit of measurement) via G-tube (a gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach) two times a day for CVA (cerebral vascular accident, or a brain attack, is an interruption in the flow of blood to cells in the brain) prophylaxis (prevention). During an interview and concurrent record review with Licensed Vocational Nurse (LVN) B on 3/8/24 at 11:20 a.m., LVN B stated for Resident 38's Apixaban, We should be monitoring for signs and symptoms of bleeding. Reviewing Resident 38's medical record indicated there was no documentation that monitoring for bleeding was documented. LVN B stated, No, it is not being done. Review of facility's policy titled Anticoagulation (Anticoagulants are sometimes referred to as blood thinners, and are drugs that prevent blood from clotting or prevent existing clots from getting larger) Clinical Protocol, dated November 2023, indicated, Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. a. Assess for evidence of effects related to the subtherapeutic (lower than that usually prescribed to treat a disease effectively) or greater than therapeutic drug level related to that drug if applicable. The staff and physician will monitor for possible complications in individuals who are being anticoagulated (a substance that hinders the clotting of blood) and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in the urine) hemoptysis (coughing up blood) or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Based on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the residents' refrigerator readily available for use when two boxes of Jevity (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition) was found unlabeled and expired in the residents' refrigerator. This failure had the potential to result in contaminated food and foodborne illnesses to an already vulnerable facility population. Findings: During a concurrent observation in the nurses' station and interview with the Director of Staff Development (DSD) on 3/6/24 at 9:31 a.m., two boxes of Jevity were observed in the residents' refrigerator. Both boxes had an expiration date of 12/1/2023 printed on the box. The DSD stated she did not think they were for anyone; the expiration dates should be checked. Review of the facility's policy and procedure titled, Resident Food Refrigerator, dated November 2023, indicated, Foods that are in their original containers and have not been opened will be kept per the manufacturer's expiration date. Licensed nurses are responsible for ensuring food items in refrigerators, and freezers are not past the expiration dates.

Based on observation, interview, and facility record review, the facility failed to ensure infection control practices were followed for one of three residents (Resident 293) when licensed vocational nurse A (LVN A) did not perform hand hygiene during medication administration. This failure had the potential for transmition of infectious agents to residents. Findings: During a medication pass observation with LVN A on 3/5/24 at 8:22 a.m., LVN A took the blood pressure of Resident 293 and sanitized the blood pressure cuff. LVN A proceeded to prepare Resident 293's medications. LVN A administered the medications to Resident 293 without performing hand hygiene. During an interview with LVN A on 3/5/24 at 8:37 a.m., she stated she should have sanitized her hands after taking the resident's blood pressure and before popping out the medicine. LVN A confirmed she did not perform hand hygiene. During an interview with the Nurse Supervisor (NS) on 3/7/24 at 9:43 a.m., the NS stated when a nurse is giving medication, they need to do hand hygiene between each task. Review of facility's policy and procedure (P&P) titled, Handwashing /Hand Hygiene , revised 10/23, the P&P indicated, Personnel are trained and on the importance of hand hygiene . Indication for Hand Hygiene 1.a. immediately before touching resident . c. after contact with blood, body fluids, or contaminated surfaces.

Based on interview, and record review, the facility failed to develop and implement care plans (a plan that provides direction on the type of nursing care the individual may need) for two of 19 sampled residents (38 and 66): 1. For Resident 38, there was no care plan that addressed the long term care of her gastrostomy tube (g-tube, a surgical opening into the stomach for administration of nutrition and medications), no care plan developed for the use of an anticoagulant (a medication that prevents or reduces blood from clotting); and, 2. For Resident 66, a care plan for diabetes was not developed. These failures had the potential for the facility to overlook care issues and render person-centered care plans lacking measures to address identified needs. Findings: 1. Review of Resident 38's face sheet indicated Resident 38 was admitted to the facility for multiple diagnoses that included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, chronic atrial fabulation (an irregular and often very rapid heart rhythm), and dysphagia (difficulty swallowing). Review of Resident 38's SBAR (Situation, Background, Assessment, Recommendation) communication forms indicated Resident 38 was transferred to the emergency department on 12/20/23 at 12:00 p.m. due to the g-tube coming out, and redness at the site, on 12/23/23 at 12:00 p.m. due to blood-tinged drainage at the g-tube site, and on 2/29/24 at 9:00 p.m. due to a dislodged g-tube. During a concurrent interview and record review on 3/7/24 at 4:22 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 38's medical record and care plans were reviewed. The care plans indicated there was no care plan for the long-term care of a g-tube. MDSC indicated there should be a care plan for the long-term care of Resident 38's g-tube. Review of Resident 38's physician orders, dated 1/6/23, indicated, Apixaban Tablet 5 milligrams (MG) (a unit of measurement) via G-tube, two times a day for CVA [cerebral vascular accident, an interruption in the flow of blood to cells in the brain] prophylaxis [prevention]. Resident 38's medical record lacked a care plan for the anticoagulation medication Apixaban. During an interview and concurrent medical record reviewed with Licensed Vocational Nurse (LVN) B on 3/8/24 at 11:40 a.m., she stated there was no care plan for the care and/or monitoring of Resident 38 for Apixaban and there should be. 2. Review of Resident 66's clinical record indicated she was admitted to the facility with diagnoses including diabetes (a condition which affects the way the body processes blood sugar) and hypertension (high blood pressure). Review of Resident 66's physician orders indicated she had two orders for insulin, one to be given at night and sliding scale insulin (set of instructions for administering insulin dosages based on specific blood glucose readings). Review of Resident 66's care plans indicated the resident had no care plan that addressed her diagnosis of diabetes or use of insulin. During an interview with the minimum data set coordinator (MDSC) on 3/8/24 at 9:32 a.m., the MDSC confirmed Resident 66 did not have a care plan for diabetes. The MDSC stated there should be a diabetes care plan for Resident 66 to monitor for signs and symptoms of hyperglycemia (high levels of sugar in the blood) and hypoglycemia (low levels of sugar in the blood). Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised 3/2023, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Controlled Drug Records (CDRs) for six random residents receiving PRN (as needed) controlled medications were requested for review during the survey. Review of Resident 47's CDR for Lorazepam 0.5 milligrams (mg, unit of measurement) indicated nursing staff signed out one tablet on 2/19/24, 2/20/24, and 2/24/24. Review of Resident 47's physician's orders indicated he had a previous physician's order for Lorazepam 0.5 milligrams to be administered every twelve hours as needed for anxiety with an end date of 2/14/24. It also indicated he had a current physician order for Lorazepam 0.5 milligrams to be administered every twelve hours as needed for anxiety with a start date of 2/26/24. During an interview with registered nurse H (RN H) on 3/6/24 at 3:21 p.m., RN H confirmed Resident 47 did not have a physician order for Lorazepam from 2/15/24 to 2/25/24. During an interview with the Nurse Supervisor (NS), on 3/7/24 09:47 a.m., the NS confirmed there was no active order during the time the three doses of Lorazeam were given. The NS further stated the nurse failed to verify to check the active orders of the Medical Administration Record (MAR). Review of the facility's policy and procedure (P&P), titled, Administering Medications, revised 4/23, it indicated Medications are administered in accordance with prescriber orders, including any required time frame. Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 19 sampled residents (Residents 38, 47, and 61) when: 1. For Resident 38, levothyroxine (a medicine used to treat an underactive thyroid gland) was not administered per the manufacturer's specification; 2. For Resident 47, Lorazepam (a prescription medication used to manage anxiety) was signed out of the resident's Controlled Drug Record (CDR, or an inventory sheet that keeps record of the usage of controlled medications) when he did not have a physician order for Lorazepam. 3. Resident 61 did not have a smoking assessment completed. These failures had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 38's face sheet indicated Resident 38 was admitted to the facility for multiple diagnoses that included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, chronic atrial fabulation (an irregular and often very rapid heart rhythm), and dysphagia (difficulty swallowing). Review of Resident 38's physician orders, dated 1/5/23, indicated Levothyroxine Sodium tablet, Give 12.5 mcg (micrograms, a unit of measure) via G-tube (gastrostomy tube is a tube inserted through the belly that brings nutrition /medications directly to the stomach) one time a day for hypothyroidism (condition in which the thyroid gland cannot make enough thyroid hormone to keep the body running normally) Give 12.5 mcg every day. Review of Resident 38's physician orders, dated 4/21/23, indicated External Feed Order in the afternoon for cyclic feed (an alternative to continuous tube feeding given at the same time each day for the same amount of time) Peptamen (a feeding formula) 1.5 at 60 ml (milliliters, unit of measure) x16 hours. Provides 960 mL (milliliters, a unit of measure)/1440 kcals (kilocalories, calories and kcal are units of measure for energy) 65 g (grams, unit of measure) of protein (a nutrient your body needs to grow and repair cells, and to work properly) Initiate at 5 p.m.- 9 a.m. Review of Resident 38's Medication Administration Record (MAR, a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) indicated Resident 38 received Levothyroxine at 9 a.m. everyday. During an interview and concurrent record review on 3/8/24 at 11:50 a.m. with Licensed Vocational Nurse (LVN) B, LVN B stated Resident 38's Levothyroxine tablets were given at 9 a.m. immediately after the g-tube feeding was stopped. Concurrent review of [NAME].com (an online evidence-based referential drug information) indicated, Administer consistently in the morning on an empty stomach, at least 30 to 60 minutes before food. Do not administer within 4 hours of calcium or iron-containing products. Review of Resident 38's tube feeding Peptamen nutritional facts indicated the nutrient composition included calcium and iron. Review of the facility's policy and procedure, Administering Medications, dated April 2023 indicated, Medications are administered in a safe and timely manner, and as prescribed . Medication administration times are determined by resident need and benefit. 3. Review of Resident 61's clinical record indicated he was admitted to the facility with diagnoses including diabetes (a condition which affects the way the body processes blood sugar) and depression. During an interview with Resident 61 on 3/4/24 at 1:11 p.m., he stated he was a smoker. Review of a list of smokers provided by the facility indicated Resident 61 was a smoker. Review of Resident 61's Admission/readmission Data Tool, dated 1/31/24, indicated for the question, Does resident smoke? the answer was No. The following questions regarding smoking were left blank: What time of day does resident like to smoke? Can resident safely light and extinguish own cigarette? Select any adaptive equipment needed for the resident (smoking apron, cigarette holder, supervision, 1:1 assistance, other); Has a plan of care been developed for safe smoking? Resident 61 did not have a smoking assessment completed. Review of Resident 61's smoking care plan, dated 3/4/24, indicated he was at risk for injury related to smoking. During an interview with the minimum data set coordinator (MDSC) on 3/8/24 at 9:36 a.m., the MDSC confirmed Resident 61 did not have a smoking assessment; and that, he should have one. Review of the facility's policy, Smoking Policy - Residents, dated 1/2024, indicated, Resident smoking status is evaluated upon admission. If a smoker, evaluation includes: a. Current level of smoking frequency. b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. Desire to quit smoking; and d. Ability to smoke safely with or without supervision.

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. An open box of tuberculin (use for skin test to determine exposure to tuberculosis) vial found in the medication refrigerator did not have an open date on the vial; 2. Medications were not properly labeled and stored in one of two inspected medication storage rooms; and, 3. Multiple loose tablets were observed in the two drawers of one medication cart. These failures had the potential for residents to receive medications with reduced efficacy, inadequately monitored medications, and unlabeled medications, which could compromise residents' health and safety. Findings: 1. During a medication room observation on 3/5/34 at 1:11 p.m., with Licensed Vocational Nurse (LVN) C, there was an open box of tuberculin vial in the medication refrigerator without an expiration date or open date written on the vial. During a concurrent observation and interview with LVN C on 3/6/24 at 9:50 a.m., LVN C confirmed there was no open date on the tuberculin vial. LVN C stated it should be thrown out since she did not know when the medication vial was opened. During an interview with the Nurse Supervisor (NS) on 3/7/24 at 9:32 a.m., the NS confirmed the tuberculin vial had no open date. During a phone interview with the Pharmacy Consultant (PC) on 3/7/24 at 4:05. p.m., the PC stated the best practice is to put the open date on the vial once its opened. During a review of facility's policy and procedure (P&P), titled, Medication Labeling and Storage, revised 2/23, the P&P indicated, Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter date for the open vials. 2. During an inspection of Medication Storage Station #3 with LVN B on 3/4/24 at 10:56 a.m., there was one bottle of Magnesium Oxide 400 mg tablet supplement, one bottle of Fish oil 500 mg soft gel dietary supplement, and one bottle of Folic acid 400 mcg tablet with no open dates to each of them. LVN B verified the medications were open with no labels of open date. During an interview with LVN B on 3/4/24 at 11:02 a.m., she stated once a medication is opened, the nurse should label it with an open date. During an interview with the NS on 3/7/24 at 9:27 a.m., the NS stated an opened medication should be discarded if it is found inside the storage room without a label to indicate the open date. Review of facility's policy and procedure (P&P), Administering Medications, revised 4/23, indicated, the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 3. During an inspection of the Station B medication cart B with LVN A on 3/6/24 at 11:02 a.m., there were multiple loose tablets observed in the middle section of the two drawers, which contained bubble packs of medications. These findings were verified by LVN A. She further stated these loose medicines should be in the drug buster (medication disposal system that deactivates non-hazardous medications). During an interview with the Director of Nursing (DON) on 3/7/24 at 9:37 a.m., she stated the assigned nurse should clean the medication cart and throw the loose meds in the drug buster. Review of facility's policy and procedure (P&P), Medication Labeling and Storage, revised 2/23, indicated, the nursing staff is responsible for maintaining medication storage preparation areas in a clean, safe, and sanitary manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five out of six sampled residents had adequate supervision to prevent them from leaving the facility unattended between [DATE] through [DATE]. The distances from the facility, identified by the staff members for these residents, were between 800 feet to 1.1 miles. In addition, the facility failed to ensure proper functioning of their Wanderguard alarm system (A signaling system used to alert staff of residents who may wander out of or leave the facility. The system consists of two devices; a signaling device (bracelet) which is attached to the resident or wheelchair and the door monitor device mounted at each exit door. The two devices interact and give off a loud continuous noise when a resident wearing the signal device passes near or through the doorway to alert the staff when a resident with a risk of elopement is leaving the facility unattended). These failures resulted in all five Residents to wander outside of the facility without staff awareness either by not hearing the alarm sound, shutting the alarm off prior to determining if a resident had eloped, and/or a defective sensor. Findings: 1. On [DATE] at 4:14 PM, the facility notified the California Department of Public Health (CDPH) that Resident 1 left the facility unattended. Review of Resident 1's clinical record indicated he was [AGE] years old and admitted to the facility with diagnoses including dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain) and cognitive communication deficit. Review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated [DATE], indicated a Brief Interview Mental Status (BIMS) score of 99 (unable to complete interview). The MDS indicated the resident had short/long term memory impairment, episodes of wandering at least four to six days but less than daily, and was able to ambulate without any assistive devices (cane, walker, or wheelchair) under supervision. Review of Resident 1's Order Listing Report (physician's orders), dated [DATE], indicated an order to have the Wanderguard on at all times as a safety measure and to monitor its function every night. Review of Resident 1's quarterly Elopement Risk Assessment, dated [DATE] at 7:48 AM, indicated he had episodes of pacing, wandering, and/or trying to get out of the facility. It also indicated he had a history of elopement; therefore, resident 1 was considered a risk for elopement. Another annual Elopement Risk Assessment, dated [DATE] at 7:48 AM, indicated he was at continued risk for elopement. Review of Resident 1's Unusual Occurrence-Elopement Final Report, dated [DATE], indicated the Administrator documented that on [DATE] at approximately 10:45 PM, a Certified Nursing Assistant (CNA) went to take vital signs (temperature, pulse, respirations, and blood pressure) and could not find the resident. She documented Resident 1 was found outside the facility and down the street at a restaurant at approximately 11:30 PM. Resident 1's Wanderguard was in place and functioning (alarming) upon return to the facility. The Administrator's documentation showed an interview with a CNA [CLP1] indicated she thought she heard the alarm sound around 10:35-10:45 PM for about 30 seconds but was attending to another resident. The CNA stated after she finished attending to the other resident, the alarm did not sound anymore. The CNA did not know who turned the alarm off. Another interview with Licensed Nurse (LN) A was conducted. She reported, at approximately 10:45 PM, she heard the alarm go off at the front door. When she arrived at the door, it was no longer sounding. Another interview statement from another LN [CLP2] indicated he heard an alarm go off, but it was disarmed quickly. He did not see anyone turn the alarm off. A Registered Nurse (RN) [CLP3] statement indicated an evening shift RN found Resident 1 down the street at a restaurant (.6 miles away). The Administrator documented under the Elopement review that Resident 1 had two Wanderguards in place (one on his ankle and one on his wrist). She concluded the Wanderguard bracelets worn by Resident 1 were in place and functional, since the alarm sounded; however, an unknown person disarmed the alarm at the front door. Review of Resident 1's Behavior Note, dated [DATE] at 8:29 AM, indicated on [DATE] at approximately 11 PM, Resident 1 could not be located inside the facility. Resident 1 was located 30-35 minutes later outside at a local restaurant with a skin tear to his left elbow. The licensed nurse documented Resident 1's Wanderguard was in working order and had not expired. Review of Resident 1's Interdisciplinary Department Team (IDT) Review note, dated [DATE] at 9:39 AM, indicated other risk factors that may have contributed to this elopement: cognitive communication deficit. The IDT recommended possible transfer to a locked facility. During a telephone interview with LVN C on [DATE] at 1:30 PM, he stated he was worked the evening shift on [DATE]. He stated he heard the Wanderguard alarm go off, but someone turned it off, so he thought the resident was found (Resident 1). LVN C stated when the Wanderguard alarm is triggered, the alarm sound stays on continuously until a staff member goes to the wall alarm box to turn it off/reset it. 2. On [DATE] at 9:21 AM, the facility notified CDPH that Resident 2 left the facility unattended. Review of Resident 2's clinical record indicated she was [AGE] years old and had a diagnosis of Alzheimer's Disease (a type of dementia). Review of Resident 2's Health Status Note, dated [DATE] at 10:53 PM, indicated at approximately 8:20 PM, a CNA began to ask staff if they had seen resident 2. Prior to this request, Licensed Vocational Nurse (LVN) A documented Resident 2 had a second Wanderguard (bracelet) added to her right wrist. Review of Resident 2's undated Unusual Occurrence-Elopement Final Report indicated, on [DATE] at approximately 8:20 PM, the same day the resident was admitted for a five-day respite stay (a short-term relief for primary caregivers), Resident 2 went missing from the facility. Resident 2 was found at a local shopping center (1.1 miles away) and returned to the facility at approximately 9 PM, still wearing her Wanderguard bracelet. Review of Resident 2's IDT Review regarding her [DATE] elopement episode indicated, risk factors identified that may have contributed to her elopement included wandering and confusion. Prior to her elopement episode, she had on two Wanderguard bracelets that triggered the alarm to sound when tested. The IDT recommended for Resident 2 to be placed on every 15-minute monitoring. The IDT concluded Resident 2 likely needed to be in a locked facility versus a secure facility. Review of Resident 2's Medical Provider SOAP Note, dated [DATE] at 6:50 PM, indicated the resident had a diagnosis of Alzheimer's dementia and was brought from home to the facility under respite care to give the resident's family member a needed break (from caring for the resident for a few days). The physician ' s assessment indicated the staff just needed to be careful regarding elopement for Resident 2 because she often tried to leave her own home. He documented Resident 2 had a Wanderguard (bracelet) in place and the staff were aware. Review of Resident 2's MDS, dated [DATE], indicated she had severe impaired cognition, ambulated with supervision, and wandered daily. 3. On [DATE] at 9:19 PM, the facility notified CDPH that Resident 3 left the facility unattended. Review of Resident 3's clinical record indicated she was [AGE] years old and was admitted to the facility with a diagnosis of Alzheimer's dementia. Review of Resident 3's MDS, dated [DATE], indicated a BIMS score of 2 (severely impaired cognition). In addition, the MDS identified the resident had daily episodes of wandering and was able to ambulate with supervision without any assistive devices (cane, walker, or wheelchair). Review of Resident 3's Order Listing Report (physician orders), dated [DATE], indicated an order to monitor the function of the resident ' s Wanderguard every night and to have it on at all times as a safety measure. Review of Resident 3's Health Status Note, dated [DATE] at 10:13 PM, indicated the resident was not in the facility at 8:22 PM. At 9:03 PM (43 minutes later), Resident 3 was located down the street at a restaurant 0.3 miles away from the facility. Review of Resident 3's IDT Review note indicated other risk factors that may have contributed to Resident 3 ' s elopement included wandering aimlessly, ambulating without assistance, history of elopement, and impulsivity. Interventions that were in place prior to her elopement included the use of a Wanderguard. Review of Resident 3's Elopement Final Report, dated [DATE], indicated the Administrator documented Resident 3 was last seen on [DATE] at approximately 8 PM before she eloped. Resident 3 was found outside the facility and down the street at a restaurant at 9:03 PM. The facility had a Wanderguard alarm system in place. The preventative maintenance log indicated the Wanderguard system was checked three times a week to ensure the system worked. The facility concluded Resident 3's Wanderguard bracelet triggered an alarm to sound both when she left the facility and when she returned to the facility. However, by the time staff reached the door after Resident 3 eloped, she was already out of site. Meanwhile, another resident with a Wanderguard bracelet simultaneously triggered the same alarm that Resident 3 triggered (upon Resident 3's elopement). This led the Charge Nurse to incorrectly believe it was only that one other resident who set off the alarm. Minutes later, a CNA alerted other staff that Resident 3 was missing. 4. On [DATE] at 1:15 PM, the facility notified CDPH that Resident 5 left the facility unattended. Review of Resident 5's clinical record indicated she was [AGE] years old and admitted to the facility with diagnoses including psychotic disorder with delusions and unspecified dementia. Review of Resident 5's Elopement Risk Assessment (during admission), dated [DATE] at 3:10 PM, indicated she was not independently mobile and had no history of elopement. Another Elopement Risk assessment dated [DATE] at 1:50 PM, indicated she ambulated independently, paces and wanders, and has a history of elopement. This [DATE] assessment also indicated Resident 5 left the facility twice while wearing a Wanderguard and was a danger to herself by inadvertently leaving the facility. Review of Resident 5's Psychiatric Diagnostic Interview, dated [DATE], indicated she was highly anxious, confused and tried to leave the facility. The NP documented Resident 5 was fearful, anxious, frustrated, and had poor attention/concentration, impulse control, insight/judgment, and recent memory. Review of Resident 5's physician ' s orders, dated [DATE], indicated an order to check the Wanderguard placement and functioning once a day. Review of Resident 5's Unusual Occurrence-Elopement Final Report, dated [DATE], indicated on [DATE] at approximately 10 PM, a CNA went into Resident 5's room and noted the resident was not in her bed. The CNA looked outside and saw the Police department were across the street at the car dealership. Resident 5 was seen sitting on a bench outside the dealership. Resident 5's Wanderguard (bracelet) was in place on her left ankle. LVN B saw Resident 5 at around 8 PM and knew the Wanderguard was on her left ankle; however, she could not remember hearing any alarm sound when the resident eloped. LVN B heard the alarm sound when Resident 5 returned to the facility. The Administrator documented Resident 5's interventions, which included changing the location of her Wanderguard from her ankle to her wrist and ordering a Psychiatric evaluation. Review of Resident 5's Medical Provider SOAP Note, dated [DATE] at 1:22 PM, indicated Resident 5 was transferred from skilled nursing facility (SNF) A to SNF B because she kept trying to leave SNF A. While the resident was at SNF B wearing a Wanderguard (bracelet), she made her way outside of the facility without the alarm going off and went across the street to a car dealership. Review of Resident 5's Minimum Data Set (MDS-an assessment tool), dated [DATE], indicated a BIMS score of 9 (moderately impaired cognition). In addition, the MDS identified the resident had episodes of wandering one to three days and was able to ambulate with supervision using a walker. 5. On [DATE] at 3:35 PM, the facility notified CDPH that Resident 6 left the facility unattended. Review of Resident 6's clinical record indicated she was [AGE] years old and admitted to the facility with diagnoses including anxiety disorder and cognitive communication deficit. Review of Resident 6's Order Listing Report, dated [DATE], indicated an order to monitor the function of the Wanderguard once a day and to have the staff check the placement of the Wanderguard every shift on her left ankle. Review of Resident 6's Elopement Risk Assessment (Admission), dated [DATE] at 9:58 PM, indicated she had episodes of pacing, wandering and/or trying to get out of the facility, and she had a history of elopement. Resident 6 was considered a high risk for elopement. Review of Resident 6's MDS, dated [DATE] indicated a BIMS score of 9 (moderately impaired cognition), ambulated with supervision, and had no history of wandering. Review of Resident 6's IDT Review note, dated [DATE] at 9:54 AM, indicated other risk factors that may have contributed to elopement included episodes of wandering and elopement risk. Previous interventions that were put in place prior to the elopement on [DATE] was a Wanderguard (bracelet). The IDT recommended to change Resident 6 from a 1:1 (one staff member always with the resident) to every 15-minute monitoring. Review of Resident 6's Elopement Final Report, dated [DATE], indicated the Administrator documented the resident had diagnoses including dementia without behavioral disturbance and cognitive communication deficit. On [DATE] at 4:50 a.m., a CNA reported she could not find Resident 6. Resident 6 was found outside the facility and down the street speaking with a man. The staff assisted Resident 6 back to the facility at around 5:10 AM and the Wanderguard (bracelet) was replaced to her right ankle. An interview with the Charge Nurse indicated Resident 6's ankle bracelet failed to trigger the alarm upon elopement; and, when the resident was brought back to the facility, the ankle bracelet was immediately replaced. During an interview with the Assistant Administrator (AA) on [DATE] at 10:20 AM, she stated the facility had five exit doors with a Wanderguard system that sounded an alarm when a resident with a Wanderguard bracelet was close to the exit door or had exited the facility. The AA stated a receptionist sat at a desk close to the front door seven days a week from 8 AM - 7:30 PM. She stated the four other exit doors lock from the outside only; and, when they were opened from the inside, an alarm would sound until a staff member would go to the control box to punch in a code that would reset the alarm. When the AA was asked if the facility had done any tracking or trending related to residents that eloped, she replied she was unaware. She stated the Maintenance Director checked the Wanderguard system every week to ensure the system functioned properly. The AA stated: a. Resident 1 was confused, combative and wandered aimlessly for hours on end. b. Resident 2 was confused and at the facility for respite care. The resident wandered around the facility and eloped the 1st day she was admitted to the facility. c. Resident 3 was confused and wandered aimlessly. The resident also had aggressive behaviors towards the staff. d. Resident 5 was confused, yelled, and was combative towards the staff. The resident wandered around the facility and was not easily directed; and, e. Resident 6's Wanderguard bracelet did not sound an alarm when she left the facility; however, it sounded an alarm when she returned. During an observation of a Wanderguard bracelet sensor, on [DATE] at 11:15 AM, the Nursing Supervisor went to the front door with the bracelet and a very loud alarm sounded until the control box on the wall was reset. During an interview with the Social Service Director (SSD) on [DATE] at 1:20 PM, she stated all the facility's exit doors have the Wanderguard alarm system installed. She was not employed at the facility until [DATE] and did not recall the residents. During an interview with Licensed Vocational Nurse (LVN) A on, [DATE] at 1:25 PM, she stated: a. Resident 1 was alert and confused. The resident was non-verbal most of the time and had behaviors including agitation and wandering from morning until night. He ambulated independently. b. Resident 2 was alert, but not oriented and not able to make her needs known. The resident's behaviors included wandering and exit seeking. She ambulated independently. c. Resident 3 was alert to person only and able to make her needs known. The resident's behaviors included wandering and exit seeking. d. Resident 5 was alert to person only. She ambulated with a walker or wheelchair and had exit seeking behaviors. e. Resident 6 was alert to person only and was able to make her needs known. The resident was transferred from SNF A to SNF B because she was exit seeking and this building (SNF B) had the Wanderguard system installed. LVN A stated all exit doors at the facility had the Wanderguard alarm system installed and the Maintenance Director checked the system every other day to ensure the alarm functioned/sounded. During an observation of the facility's exit doors with the AA on [DATE] at 2:50 PM, all five exit doors had alarms that sounded off very loudly when a Wanderguard bracelet sensor was brought near to trigger them. The AA had to manually input a code in the code box on the wall to silence and reset the alarm system. Review of the facility's policy and procedure (P&P) Wandering and Elopements, revised 3/2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If residents are identified to be at risk for wandering/elopement, their care plans will include strategies and interventions to maintain their safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment and screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one resident (Resident 1). This deficient practice had the potential to result in the delay of resident assessments. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including cellulitis (inflammation of the skin) of right lower limb. A review of Resident 1's Discharge Assessment with Assessment Reference Date (ARD) dated 7/21/21, indicated Resident 1 was discharged to the community . During a concurrent interview and record review with the minimum data set nurse (MDSN) on 12/13/21 at 8:52 a.m., the MDSN confirmed Resident 1 was discharged on 7/21/21 and the MDS was exported. The MDSN stated she finished the Discharge Assessment on 9/21/21 and did not follow-up if Resident 1's MDS was accepted or not. Review of facility's policy , Resident Assessment, dated 11/2019, indicated A comprehensive assessment of every resident's needs was made at interval designated by OBRA and PPS requirements. A review of the CMS website (https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v115R-October-1-2018-R.pdf) indicated, .Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for two of 18 sampled residents (Residents 7 and 78) when the MDS did not reflect the current status of the residents. This failure had the potential to affect inappropriate care planning and intervention. Findings: 1. Review of Resident 7's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including encounter with palliative care (care aimed to optimized quality of life), secondary malignant neoplasm of bone (unusual cells growing in the bone), squamous cell carcinoma (skin cancer) Review of Resident 7's physician order dated 6/23/21 indicated to admit to [name of hospice]. During a concurrent interview and record review with the minimum data set nurse (MDSN) on 12/9/21 at 9:21 a.m., the MDSN confirmed Resident 7 was admitted to hospice on 8/10/2020. The MDSN reviewed the MDS and stated there was no significant changed done to the MDS. During an interview with the MDSN on 12/9/21 at 12:00 p.m., the MDSN stated when Resident 7 was admitted to hospice when he was admitted to the facility. The MDSN further stated the hospice treatment was not coded in the MDS. Review of Centers for Medicare and Medicaid Services 10/2019 (CMS, a federal agency) Resident Assessment Instrument User's Manual (RAI Manual, MDS coding instructions) indicated for Section O0100K, Code residents identified as being in hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. 3. Review of Resident 78's electronic record, did not indicate that Resident 78 had a diagnosis of epilepsy, although he was being administered medication for epilepsy. During an interview on 12/10/2021 at 1:38 p.m. with licensed vocational nurse A (LVN A), LVN A stated Resident 78 does not have a diagnosis of epilepsy or seizures listed under his list of diagnoses. During an interview on 12/10/2021 at 1:48 p.m. with medical records staff (MR), MR stated Resident 78 had a diagnosis of epilepsy on 10/5/18, which had been from a previous admission. MR stated Resident 78 had been discharged on 9/20/2021 with return anticipated. When Resident 78 was re-admitted on [DATE], his diagnosis of epilepsy was not carried over. Review of Resident 78's hospital discharge notes dated 9/29/2021 indicated a Health Concern of seizure disorder. During an interview with the MDSN on 12/10/2021 at 2:13 p.m., the MDSN stated Resident 78's epilepsy diagnosis was in the electronic record from the past. It was accidentally changed to resolved. During an interview with the MDSN on 12/10/2021 at 3:15 p.m., the MDSN stated reactivation of Resident 78's diagnosis of epilepsy was not done on readmission, it just needed to be reactivated. During an interview with the MDSN on 12/13/2021 at 9:01 a.m., the MDSN stated, Resident 78 was not being monitored for seizures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority) for two of 18 sampled residents (Residents 71 and 49). This failure had the potential to put the residents at risk for not receiving appropriate care and services. Findings: 1. Review of Resident 71's clinical record indicated he was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including major depressive disorder (persistent feeling of sadness and loss of interest) unspecified psychosis (abnormal thinking and perceptions). Review of Resident 71's PASSR dated 10/1/19, did not indicate a diagnosis of psychotic or psychosis disorder. During a concurrent interview and record review with the nursing supervisor (NS) on 12/7/21 at 4:21 p.m., the NS reviewed Resident 71's PASSR and confirmed the diagnoses of unspecified psychosis was not coded. 2. Review of Resident 49's clinical record indicated he was admitted on [DATE] with a diagnosis including unspecified dementia with behavioral disturbance and unspecified psychosis. Review of Resident 49's PASSR dated 4/8/21, it did not indicate a diagnosis of psychotic or psychosis disorder. During an interview with the NS on 12/9/21 at 9:55 a.m., the NS confirmed the diagnoses of unspecified psychosis was not coded. Review of facility's policy, admission Criteria, dated 3/2019, indicated The objectives of our admission criteria policy are to: admit residents who can be cared for adequately by the facility .all new admissions and readmissions were screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid ASA process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to post the daily nurse staffing number of hours ratios (PHPPD) in a prominent place, which was easily visible to all. This failure had potential to affect residents' care due to the lack of nursing working hours information. Findings: During an interview on 12/13/2021 at 9:28 a.m. with the staffing and central supply staff (CSS), CSS stated the PHPPD is posted in the back of the building. During an observation on 12/13/2021 at 10:21 a.m., accompanied by CSS, CSS pointed out where the PHPPD was posted, which was near the back entrance, which leads to the parking lot, near room [ROOM NUMBER]. During an interview on 12/13/2021 at 11:02 a.m. with the administrator (ADM), the ADM stated the PHPPD has always been posted by the back door, where the parking lot is located. Before COVID, that was where people entered the facility. Now the only entrance was the front door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 18 sampled residents (Residents 10 and 52) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. For Resident 10, the facility failed to address the continued use of a PRN (as needed) psychotropic medication in a timely manner. The facility failed to ensure there was a specific duration of use for a PRN psychotropic medication that exceeded 14 days. 2. For Resident 52, Seroquel (medication used to treat mental/mood conditions) did not have specific manifestation and orthostatic hypotension was not monitored. These failures could result in lack of adequate monitoring and had the potential for the residents to receive unnecessary medications. Findings: 1. Review of Resident 10's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including encounter with palliative care (comfort care) anxiety disorder (feeling of worry and fears). Review of Resident 10's physician order dated 10/20/21 indicated Ativan (a medication for anxiety) 0.5 milligrams (mg, unit of measurement) 1 tablet every 12 hours as needed for behavioral syndromes associated with physiological disturbances and physical factors (behavior disorders) manifested by hitting, kicking staff. Review of Resident 10's physician order dated Lorazepam (Ativan) solution give 0.25 milliliters (ml, unit of volume) every 2 hours as needed for mild/moderate anxiety as manifested by hitting and kicking staff. Review of Resident 10's physician order dated 11/29/21 indicated Lorazepam solution give 0.5 ml every 2 hours as needed for severe anxiety as manifested by hitting and kicking staff. During an interview with the nursing supervisor (NS) on 12/13/21 at 9:57 a.m., the NS confirmed the above orders did not have a stop date. The NS further stated it should have a stop date. During an interview with the consultant pharmacist (CP) on 12/13/21 at 12:14 p.m., the CP confirmed the above order did not have a stop date. Review of the facility's policy, Psychotropic Medication Use dated June 2021, indicated psychotropic PRN orders are limited to 14 days. 2. Review of Resident 52's clinical record indicated she was admitted on [DATE] with diagnoses including unspecified dementia with behavioral disturbance (memory loss) and major depressive disorder (persistent feeling of sadness and loss of interest). Review of Resident 52's physician order dated 8/12/21 indicated Seroquel (an antipsychotic medication use to treat mental/mood conditions) 50 mg in the evening for unspecified dementia with behavioral disturbances evidence by agitation. Review of Resident 52's medication regimen review (MRR, a detailed review of all the current medication a patient is taking to identify adverse effects) dated 8/7/21 indicated This Resident has an antipsychotic order for psychosis, m/b [manifested by] agitation. The MRR recommendation was to clarify the behavior manifestation to be more specific. Review of Resident 52's MRR dated 10/19/21 indicated This Resident has an antipsychotic order for psychosis, m/b agitation. The MRR recommendation was to clarify the behavior manifestation to be more specific. During an interview with licensed vocational nurse N (LVN N) on 12/10/21 at 12:27 p.m., LVN N stated Resident 52 had episodes of yelling out and being combative if staff was trying to calm her down and talking to the walls. During an interview with the CP on 12/10/21 at 2:41 p.m., the CP stated the behavior manifestation of agitation should had been more specific. During an interview with the NS on 12/13/21 at 10:05 a.m., the NS confirmed the behavior manifestation of agitation was not specific. Review of the facility's policy, Antipsychotic Medication Use dated 12/2016, indicated Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer warfarin (Coumadin, a medication that can treat and prevent blood clots) for atrial fibrillation (a-fib an irregular heartbeat that can cause poor blood flow) for one of 18 sampled residents (Resident 71). This deficient practice resulted in Resident 71 not receiving seven scheduled doses of the medication in October, 14 doses in November, seven doses in December 2021 a period of 28 days and put the resident at risk for developing a stroke (damage to the brain from interruption of its blood supply). Findings: Review of Resident 71's clinical record indicated he was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a-fib, dementia (memory loss) and unspecified psychosis (abnormal thinking and perceptions). Review of Resident 71's physician order dated 12/24/20 indicated, warfarin 5 milligrams (mg, unit of measurement) one tablet by mouth in the evening every Monday, Tuesday, Wednesday, Thursday, Saturday and Sunday for a-Fib. Additional review of the physician order dated 12/24/2020 indicated warfarin 7.5 mg one tablet by mouth in the evening every Friday for a-fib. A review of Resident 71's November 2021 medication administration record (MAR) indicated on November 7, 8, 10, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30 a total of 13 days his warfarin 5 mg medication were signed as 10 (10, chart code for other) Review of the November 2021 eMar-Medication Administration Note on the above dates for the warfarin 5 mg medication indicated the medication was not available. Further review of Resident 71's MAR indicated warfarin 7.5 mg 1 tablet every Friday was signed 10 on 11/26/21. The eMar note indicated none on hand. Additional review of Resident 71's December 2021 MAR indicated the following: Warfarin 5 mg 1 tablet was signed as 10 on 12/1, 12/2, 12/4, 12/5, 12/6, 12/7. The eMar-Medication Administration Note on the dates the medication was signed 10 indicated the medication was not available. Resident 71's warfarin 7.5 mg 1 tablet every Friday was signed 10 on 12/3/21. The eMar-Medication Administration Note indicated the medication was on order. During an interview with the Doctor of Medicine (MD) on 12/9/21 at 3:06 p.m., the MD stated the pharmacy was not dispensing Resident 71's warfarin medication and the facility did not notify him. The MD further stated Resident 71's PT/INR (PT; prothrombin time/international normalized ratio, a test to determine the effect of Coumadin; it measures how long it takes, in seconds, for blood clot. The American College of Cardiology Physicians guidelines for Antithrombotic Therapy for the Prevention and Treatment of Thrombosis [clotting of the blood] recommends a therapeutic [target] INR range of 2.0 to 3.0 in patients receiving Coumadin for atrial fibrillation) on 12/9/21 was 1.1. The MD explained an INR of 1.1 puts Resident 71 at risk for stroke. The MD futher stated the facility should have called him if the pharmacy did not dispense the medication because he was responsible for the resident's anticoagulation therapy (anticoagulants, use to treat blood clots). During a concurrent interview and record review with the minimum data set nurse (MDSN) on 12/9/21 at 4:57 p.m., the MDSN reviewed Resident 71's MAR and eMar notes and confirmed the resident did not receive his warfarin medication in multiple days. During a concurrent interview and record review with the nursing supervisor (NS) on 12/10/21 at 8:12 a.m., the NS reviewed Resident 71's October 2021 MAR and confirmed the medication was not given on 10/10, 10/11, 10/18-10/21 and 10/28, total of 7 days. The NS stated if the medication was not on hand, his expectation was for the licensed nurses (LN) to notify the physician and document the physician's response. If the attending physician (AP) did not respond, the LNs should follow-up the next day. The NS further stated his expectation was for the LNs to contact the pharmacy and document the pharmacy's response. Review of the October 2021 eMar notes provided by the facility indicated the following: On 10/10/21- medication is unavailable, reorder sent to pharmacy On 10/20/21-no medication on hand On 10/21/21-pharmacy has been notified about warfarin reorder On 10/28/21-none on hand The above eMar notes did not indicate the AP or the MD were notified regarding the medication not being given. There was no documentation provided regarding follow ups made to the pharmacy and/or pharmacy's response. During an interview with licensed vocational nurse G (LVN G) on 12/13/21 at 11:21 a.m., LVN G stated she recently called the pharmacy regarding Resident 71's warfarin medication because it was not available and was told the AP was the prescriber and it was not the MD. LVN G further stated she did not document the response of the pharmacy. LVN G stated if the medication was not available, the protocol was to call the pharmacy and if the pharmacy would not dispense the medication, the next step was to notify the physician. During an interview on 12/13/21 at 1:39 p.m., with the director of nursing (DON), the DON stated he was informed by the pharmacy that six tablets of the warfarin 5 mg and two tablets of the warfarin 7.5 mg were delivered on 11/12/21. There was no delivery manifest (delivery receipt or delivery list documentation) provided. Review of Resident 71's November and December 2021 MAR indicated, he did not receive the 5 mg of warfarin from 11/2020 to 12/7/21 and did not receive the 7.5 mg of warfarin on two consecutive Fridays on 11/26/21 and 12/3/21 when they were due. According to https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/009218s108lbl.pdf indicated Coumadin is indicated to reduce the risk of death, recurrent myocardial infarction, and thromboembolic events such as stroke or systemic embolization after myocardial infarction. Review of the facility's policy Administering Medications dated 4/2019 indicated Medications are administered in a safe and timely manner, and as prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications and biologicals were stored appropriately when a medication was left on Resident 34's bedside table and an unopened bottle of Latanoprost was not refrigerated. These failures had the potential to result in the access of medications by unauthorized personnel or residents and use of medications being used past the expiration date. Findings: 1. During an observation on 12/6/21 at 10:20 a.m., there was one tablet in a medication cup on Resident 34's bedside table. During a concurrent interview, Resident 34 stated she was going to take it last night but she fell asleep. During a concurrent interview, certified nursing assistant M (CNA M) confirmed there was a medication on Resident 34's bedside table and stated there should not be medication there. During an interview on 12/6/21 at 10:22 a.m., the director of nursing (DON) took the medication from Resident 34's bedside table and stated medication should not be left unattended. 2. During inspection of Medication Cart 1 on 12/6/21 at 1:55 p.m. with minimum data set nurse (MDSN), an unopened container of latanoprost (an eye drop medication to treat high pressure in the eye) was identified. During a concurrent interview, the MDSN stated the unopened latanoprost should be refrigerated. According to Lexi-comp (www.[NAME].com, a nationally recognized drug information resource), intact bottles of latanoprost solution should be stored under refrigeration and once opened, the container may be stored at room temperature for 6 weeks.

Based on observation, interview, and facility document review, the facility failed to ensure staff competency when one of four cooks (Cook 2) did not follow a recipe for the preparation of vegetables which were bland and not palatable. This failure had the potential a decreased intake of food for residents who ate food from the kitchen. Findings: On 12/7/21 at 12:30 p.m., due to resident food complaints (Cross-reference F804), a test tray to sample resident food was conducted in the presence of the Registered Dietitian (RD) and the Dietary Services Supervisor (DSS). The observation showed the regular mixed vegetables were mushy and bland, and the pureed vegetables were bland. The RD stated the vegetables could use more salt. In an interview on 12/7/21 at 12:50 p.m., [NAME] 2 stated she cooked the regular and pureed vegetables that day. She stated she took the frozen vegetables out of the box and placed them in the oven in a covered pan. She stated the only ingredient she added to the vegetables was butter. She said she placed the vegetables in the oven about 10 a.m., and they took about 35 minutes to cook. Review of the recipe, titled Capri Blend Veg dated 2002-2021, for provided for the vegetables prepared for lunch on 12/7/21, showed ingredients in addition to the vegetables and butter included salt, granulated garlic, and black pepper. The directions showed to steam the vegetables using pressure or without pressure. Using pressure steaming from 1 minute to 12-15 minutes. Without using pressure, the vegetables were to cook for 5-7. The recipe stated, Vegetables should be slightly crisp. The recipe showed to puree they prepared vegetables for the pureed diet. Review of the undated job description titled Cook, showed a cook was responsible for following recipes and preparing and serving meals that were palatable and appetizing in appearance. Review of the In-Service Meeting Minutes titled Portion Control/Portion Sizes/Following Recipes dated 7/19/21, showed [NAME] 2 was provided training on how to follow a standardized recipe.

Based on interview and record review, the facility failed to ensure one of five residents (Resident 48) were offered and/or received pneumococcal vaccinations. This failure had the potential to expose residents to pneumococcal infections (caused by common bacteria (streptococcus pneumonia) that can affect different parts of the body). Findings: Review of Pneumococcal Vaccination Consent Form dated 1/9/21 indicated, responsible party (RP, person who is accountable in making decision in behalf of the resident) consented for the PNA vaccine to be given. Review of the immunization list provided by the facility, indicated Resident 48 did not have the PNA immunization. During an interview with the infection preventionist (IP) on 12/13/21 at 12:11 p.m., the IP confirmed the PNA vaccine was not followed up. Review of the facility's policy, Pneumococcal Vaccine dated August 2016 indicated, All residents will be offered pneumoccoal vaccines to aid in preventing pneumonia/penumoccoccal infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was available and completed for five of five residents (8, 33, 54, 282, and 283) reviewed under the advance directive care area. These failures had the potential to result with inability to make medical decisions when residents cannot make for themselves and could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goals and wishes. Findings: Review of Resident 8's admission record indicated he was admitted on [DATE] with a diagnosis including diabetes mellitus (a condition that occurs when the body cannot use glucose [a type of sugar] normally). Review of Resident 8's POLST dated 8/20/21, indicated an incomplete section regarding AD. Resident 8 did not have an AD on file. Review of Resident 33's admission record indicated he was admitted on [DATE] with a diagnosis including severe protein calorie malnutrition. Review of Resident 33's POLST dated 11/29/21, indicated an incomplete section regarding an AD. Resident 33 did not have an AD on file. Review of Resident 54's admission record indicated he was admitted on [DATE] with a diagnosis including Covid-19 (type of infectious disease). Review of Resident 54's POLST dated 2/25/21, indicated an incomplete section regarding an AD. Resident 54 did not have an AD on file. Review of Resident 282's admission record indicated he was admitted on [DATE] with a diagnosis including chronic obstructive pulmonary disease (COPD, a lung disease). Review of Resident 282's POLST indicated an incomplete section regarding an AD. Resident 282 did not have an AD on file. Review of Resident 283's admission record indicated he was admitted on [DATE] with a diagnosis of dementia (loss of thinking ability, memory, attention, logical reasoning, and other mental abilities). Review of Resident 283's POLST indicated an incomplete section regarding an AD. Resident 283 did not have an AD on file. During an interview and concurrent record review with the social service director (SSD) on 12/8/21 at 8:20 a.m., the SSD confirmed Residents' 8, 33, 54, 282, and 283 did not have a complete POLST to address the AD and verified that AD should be available in a resident medical record if indicated. Review of facility's policy Advance Directives , dated 12/2016, indicated Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, his/her family members and /or his or legal representatives about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 10's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including dysphasia (deficiency in generation of speech) following cerebral infarction, chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing related problems). During a concurrent interview and record review, with the MDSN on 12/8/21 at 2:34 p.m., the MDSN reviewed Resident 10's clinical record and stated the resident was hospitalized on [DATE] due to abnormal vital signs. 5. Review of Resident 52's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi) and sepsis (body's extreme response to infection). Review of Resident 52's eInteract transfer form dated 8/8/21 indicated she was transferred to an acute care hospital. During an interview with the social services director (SSD) on 12/13/21 at 11:14 a.m., the SSD stated the long-term care Ombudsman was not notified for Resident 10 and Resident 52's hospitalization. 6. Review of the facility's census list indicated Resident 33 was transferred to the acute hospital on the following dates: 8/19/21, 8/24/21, 11/1/21, 11/5/21, and 11/24/21. During an interview and concurrent record review with the SSD on 12/8/21 at 12:10 p.m., she stated there was no process to notify the Ombudsman regarding residents' hospitalization. The SSD acknowledged the Ombudsman was only notified for residents' discharges and when leaving against medical advice. Review of the facility's policy, Transfer or Discharge Notice dated December 2016, indicated the facility shall notify the Office of the State Long-Term Care Ombudsman. Based on interview and record review, the facility failed to notify the State Long-Term Care Ombudsman (Ombudsman) when six of six sampled residents (Residents 46, 30, 68, 33, 10, 52 and 33) were transferred to the hospital without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights. Findings: 1. Review of Resident 46's electronic record indicated, Resident 46 had right shoulder pain after he had an unwitnessed fall on 11/2/2021. Resident 46 was transferred to the hospital for evaluation. 2. Review of Resident 30's electronic record indicated, Resident 30 had an unwitnessed fall on 9/29/2021 and was sent to the hospital because she had a left forearm bruise and her nose was swollen/bleeding. The diagnoses from the hospital included a diagnosis of forehead contusion (bruise), fractured (broken) nasal bone, right knee swollen, and skin abrasion (scrape) under right knee. 3. Review of Resident 68's electronic record indicated Resident 68 was sent to the hospital on 9/3/2021 because of a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. Review of Resident 14's face sheet indicated Resident 14 is a [AGE] year-old male with a history of peripheral vascular disease (PVD, reduced blood flow to limbs increasing risk of stroke), end stage renal disease (kidneys not functioning effectively and requiring dialysis to remove waste from the blood) and left sided colitis (chronic inflammation of lining of small intestines) with rectal bleeding. During an interview and concurrent record review with the NS on 12/10/2021 at 1:07 p.m., the NS confirmed Resident 14 was on the medication Plavix once daily for PVD. The NS confirmed Resident 14 was scheduled for a colonoscopy on 12/6/2021. During an interview and concurrent record review with the NS on 12/10/2021 at 1:07 p.m., the NS stated the facility was notified via telephone on the 12/3/2021 to stop administering the medication Plavix on 12/1/2021 prior to the scheduled colonoscopy on 12/6/2021. The NS confirmed the facility did not administer the Plavix to Resident 14 on 12/4/2021, 12/5/2021, and 12/6/2021. The NS stated the facility administered the colonoscopy preparation (prep) on 12/6/2021 to completely empty the bowel for the procedure. The NS stated Resident 14 was sent out for the colonoscopy, but the procedure was not performed since he was administered the Plavix on 12/1/2021 and 12/3/2021. During an interview on 12/07/21 at 9:27 a.m., Resident 14 stated he went to the hospital yesterday for a colonoscopy. He stated there was lack of communication because he was supposed to stop taking a blood-thinning medication a week prior to the colonoscopy. Resident 14 stated the surgeon did not want to go through with the procedure because the medication was not stopped for a week. Resident 14 stated he cleaned his colon and did not eat for three days. He stated he was not happy because he did all the preparation and did not have the colonoscopy done. During an interview with the NS, on 12/13/2021 at 11:51 a.m., the NS stated the nurses should have known to hold the medication Plavix and should have called the physician who would be performing the colonoscopy to alert the physician the Plavix medication was not held earlier in the week prior to procedure. During an interview with the administrator (ADM), on 12/13/2021 at 10:59 a.m., the ADM stated the facility notified a facility physician the Plavix medication was given on 12/1/2021 and 12/3/2021. The ADM stated the facility physician wanted the physician performing the colonoscopy to be contacted by nursing to see if the facility should proceed with the colonoscopy prep since Plavix was taken recently. The ADM stated she had no documentation the physician performing the colonoscopy was contacted. During an interview with the NS, on 12/13/2021 at 11:51 a.m., the NS stated he could not provide documentation nursing contacted the physician performing the colonoscopy to see if the facility should proceed with the colonoscopy prep since Plavix was recently taken. During an interview and concurrent record review with Licensed Vocational Nurse N (LVN N), on 12/13/2021 at 11:37 a.m., LVN N stated Resident 14's colonoscopy did not occur because the medication Plavix was not held for the week prior to the procedure. He stated nurses should know to hold this medication as it is a blood thinner and the risk would be bleeding. He stated it is nursing knowledge. He stated the risk would be bleeding because the colonoscopy procedure is invasive. He stated the nurses should have notified the doctor Resident 14 was administered the medication prior to completing the colonoscopy prep. He stated the procedure was rescheduled since the medication was not held and the resident would need to do the prep again prior to the procedure. Record review of Resident 14's physician orders, in the Order Summary Report, indicated the Resident 14 was ordered 75 mg of Plavix daily on 10/29/2021. Record review of Resident 14's Medication Administration Record (MAR), indicated Resident 14 was administered Plavix 75 mg on 12/1/2021 and 12/3/2021. On 12/2/2021, the MAR indicated Resident 14 refused the medication. Record review of Resident 14's MAR indicated on 12/6/2021, Resident 14 was administered two of the Suprep Bowel Prep Kit Solution for colonoscopy at 7:53 a.m. Record review of the facility's policy titled Administering Medications, revised April 2019, indicated the nurse should contact the prescriber to discuss any concerns regarding medication and potential adverse consequences. 7. During an observation on 12/6/21 at 12:59 p.m., Resident 70 was lying in her bed, her call light button was clipped at the head spring part of her bed. Resident 70 was asked if she can reach her call light button, but she was unable to reach it. During a concurrent observation and interview with the DON on 12/6/21 at 1:06 p.m., the DON confirmed the above observation. During an interview with CNA O on 12/9/21 at 8:32 a.m., CNA O stated Resident 70 was capable of using her call light button if it was near to her. Review of the facility's policy Answering the Call Light, dated 3/2021, indicated When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 8. During an observation on 12/6/21 at 9:56 a.m., Resident 71 was on the bed mattress on the floor with no clothes and appeared looking at something. During an interview with CNA O on 12/06/21 at 9:59 a.m., CNA O confirmed the above observation and stated Resident 71 had episodes of removing his clothes. Review of Resident 71's care plan dated 1/7/2020 indicated resident had potential to demonstrate physical behaviors (grabbing, hitting and punching) toward staff members. The care plan was revised on 6/8/21. Review of Resident 71's care plan nutritional problem or potential nutritional problem indicated the target date was 11/16/21. Resident 71's care plan regarding resistive to care was last revised 6/28/21. During an interview with CNA P on 12/8/21 at 8:03 a.m., CNA P stated Resident 71 had episodes of removing his clothes. During a concurrent interview and record review with the minimum data set nurse (MDSN) on 12/9/21 at 8:59 p.m., the MDSN reviewed Resident 71's care plans and confirmed they were not revised and re-evaluated. The MDSN acknowledged the care plans should had been re-evaluated during the target date. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated 12/2016, indicated the interdisciplinary team must review and update care plan when the desired outcome is not met. 9. Review of Resident 76's clinical record indicated she was admitted to the facility on [DATE] with end stage of renal disease (kidney failure). During a concurrent interview and record review with MDSN on 12/7/21 at 4:37 p.m., the MDSN reviewed the bowel and bladder assessment of Resident 76 and stated the assessment was a combination and does not indicate if it was a bladder or bowel. When asked if how she determines if a resident was incontinent and continent, the MDSN stated she based it in the assessment and the task. Review of Resident 76's task indicated she had episode of incontinent and continent. Review of Resident 76's minimum data set (MDS, an assessment tool) dated 11/7/21, indicated she was occasionally incontinent (less than 7 episodes of incontinence) During an interview with the MDSN on 12/8/21 at 9:40 a.m., the MDSN stated the facility will be re-stating the bowel and bladder assessment. Review of Centers for Medicare and Medicaid Services 10/2019 (CMS, a federal agency) Resident Assessment Instrument User's Manual (RAI Manual, MDS coding instructions) indicated for Section H, Determining the type of urinary incontinence can allow staff to provide more individualized programming or interventions to enhance the resident's quality of life and functional status. Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for 10 of 18 sampled residents (Resident 33, 54, 282, 21, 48, 9, 70, 71, 76 and 14) when: 1. Resident 33, facility staff failed to address nail care, ensure oxygen (a colorless and odorless gas that people need to breathe) and diet order was administered as specified in the physician's order; and his indwelling catheter care plan was initiated timely; 2. Resident 54 did not receive his restorative nursing assistant treatment (RNA) as specified in the physician's order; 3. Resident 282 did not have a care plan for the use of oxygen; 4. A licensed staff crushed a medication without a physician's order for Resident 21; 5. Resident 48 did not have an initial care plan within 48 hrs from admission; 6. An extended release medication for Resident 9 was crushed; 7. Resident 70's call light was not within reach; 8. Resident 71's care plan was not re-evaluated; 9. Resident 76, bladder re-training program was not implemented; 10. Nurses did not hold Resident 14's Plavix (generic clopidogrel, blood thinner to prevent stroke and other heart problems) prior to a scheduled colonoscopy. These failures had the potential to compromise the residents' health and well-being. 1. Review of Resident 33's admission record indicated he was admitted to the facility with a diagnosis including severe protein calorie malnutrition and on palliative care (specialized medical care for people living with a serious illness) Review of Resident 33's order summary dated 12/8/21, indicated the following orders: - On 10/25/21, Fortified /High Protein Diet, Mechanical Soft texture, Nectar Mildly Thick consistency; - On 11/28/21, Change Foley catheter and bag PRN (as needed) for leaking, plugged, pulled out, obstruction excessive sedimentation or when the closed system is compromised; - On 8/30/21, Podiatry consult and treatment as needed and - On 12/3/21, oxygen 2 liters (L/type of measurement) continuously nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source) every shift for comfort. Review of Resident 33's MDS dated [DATE], indicated a Brief Interview for Mental Status (BIMS) of 7 (meaning severe impairment) and he needed extensive assistance with one person physical assistance with personal hygiene. Review of Resident 33's care plan dated 8/26/21, indicated Resident 33 has Activity of Daily Living (ADLs) self-care performance deficit related to impaired imbalance, limited mobility, pain, and his interventions under personal hygiene included Resident 33 required cuing and physical assistance with personal hygiene. His undated care plan indicated Resident 33 at risk for aspiration due to decline in swallow function and interventions included development of safe swallow strategies and precautions. Resident 33's indwelling catheter care plan was developed on 12/7/21, seven days after Resident 33 had an order for indwelling catheter. Resident 33's care plan did not indicate he has refusal to treatment . During an observation with licensed vocational nurse I ( LVN I ) on 12/8/21 at 9:13 a.m., Resident 33's fingernails were long, pressing on his right palm, yellowish colored and had some particles under nail bed. His toenails were observed long and coiled. LVN I confirmed the observation and stated he needed to be seen by a podiatrist and his nails need to be trimmed. During an interview with certified nursing assistant B (CNA B) on 12/8/21 at 10:54 a.m., she stated she did not notice Resident 33's nails were long and she just cut them today. During an observation on 12/7/21 at 12:10 p.m., Resident 33 had a carton of juice with a white straw on his table. On the wall above his bed, a signage Safe Swallow Alert .Thickened liquids only. During a concurrent interview with CNA B, she stated she served Resident 33 with the juice and it was not thickened. CNA B acknowledged the juice came from the snack tray with Resident 33's name on it but she did not check if the juice consistency was appropriate for him. During an interview with the speech therapist (ST) on 12/8/21 at 12:17 p.m., the ST stated Resident 33 should not be given a thin liquid consistency for greater risk of aspiration. During an observation on 12/6/21 at 10:27 a.m. and on 12/7/21 at 8:10 a.m., Resident 33's oxygen reading was on 1.5 liter. During an observation with LVN I on 12/8/21 at 9:45 a.m., Resident 33's oxygen reading was at 1.5 Liter. During an interview with the director of nursing (DON) on 12/8/21 at 11:20 a.m., the DON acknowledged licensed nurses should follow Resident 33's oxygen order. During an observation on 12/6/21 at 10:32 a.m., Resident 33 was lying in bed. The urine collection bag for his indwelling catheter was hanging on the right side of his bed. Review of Resident 33's care plan dated 12/7/21 indicated an indwelling catheter. During an interview with the nursing supervisor (NS) on 12/9/21 at 9:49 a.m., the NS confirmed the indwelling catheter care plan was not initiated timely. Review of facility's policy, Fingernails/Toenails, dated 2/2018, indicated The purpose of this procedure were to clean the nail bed, to keep nails trimmed and to prevent infections. Review of facility's policy, Oxygen Administration dated 10/2010, indicated The purpose of this procedure was to provide guidelines for safe oxygen administration. Review of facility's policy, Activities of Daily Living (ADLs), Supporting dated 3/2018, indicated Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Review of Resident 54's admission record indicated he was admitted to the facility with a diagnosis including contracture of muscle, multiple sites. Review of Resident 54's order summary report indicated the following: on 9/19/19, RNA: Apply splints (type of supportive device) to L (Left) wrist/ hand 6 hours a day 5x/wk (week) or as tolerated every Monday, Tuesday, Wednesday, Thursday, and Sunday. PROM/AAROM (Passive Range of Motion to B (Bilateral) UE 5x/wk or as tolerated every Monday, Tuesday, Wednesday, Thursday, and Sunday. On 12/10/19, RNA: Hamstring stretches 3x/wk or as tolerated every Tuesday, Thursday, and Sunday. Review of Resident 54's care plan dated 11/12/18, indicated at risk for decline in range of motion, risk of deformity and/or contracture formation and interventions included to apply splints to Left wrist 5x/wk (times/week) 4-6 hours/day or as tolerated, hamstring stretches 3x/wk or as tolerated, and PROM/AAROM (Passive range of motion/Active assisted range of motion) to B (Bilateral) UE 5x/wk or as tolerated. During an observation on 12/7/21 at 9:32 a.m. and 12/9/21 at 11:51 a.m., Resident 54 was lying in bed with his left arm contracted and no splints. During an interview with CNA B on 12/9/21 at 9:10 a.m., she stated the RNA was the one to apply the splint but there was no steady RNA for awhile. CNA B found the splint on top of a drawer. During an interview and concurrent record review with LVN K on 12/9/21 at 9:17 a.m., she confirmed Resident 54's order for RNA and application of splint was not followed. During an interview with the NS on 12/9/21 at 2:19 p.m., the RNA schedule/binder was reviewed and the NS acknowledged Resident 54 was not provided a RNA visit for the month of October 2021. For the month of November 2021, Resident 54 received one RNA visit. The NS stated there was no one to complete the weekly RNA visits or oversee the facility's RNA program. Review of facility's policy, Resident Mobility and Range of Motion dated 7/2017, indicated Residents with limited range of motion will receive treatment and services to increase and/ or prevent a further decrease in ROM . Review of facility's policy, Restorative Nursing Services dated 7/2017, indicated Residents would receive restorative care as needed to help promote optimal safety and independence. 3. Review of Resident 282's admission record indicated he was admitted on [DATE] with a diagnosis including chronic obstructive pulmonary disease (COPD, a lung disease). Review of Resident 282's order summary report dated 11/6/21, indicated oxygen 2 liters (L, a type of unit measurement) as needed. During an interview and concurrent record review with the NS on 12/9/21 at 9:26 a.m., Resident 282's care plan did not include the use of oxygen. The NS stated Resident 282 should have a care plan initiated for oxygen. Review of the facility's policy Oxygen Administration, dated 10/2010, indicated to review the resident's care plan to assess for any special needs of the resident. 6. During an observation on 12/8/21 at 9:38 a.m., LVN F prepared medications for Resident 9. LVN F crushed Resident 9's medications, including a tablet of oxybutynin (medication used to treat overactive bladder) ER (extended release) five milligrams (mg). During an interview on 12/8/21 at 9:57 a.m., LVN F reviewed Resident 9's medication pack for oxybutynin and acknowledged it indicated, Do not crush. LVN F stated she knew not to crush extended release medications, but she forgot. Review of Resident 9's physician orders indicated he had an order dated 11/29/2020, for oxybutynin chloride ER tablet extended release 24 hour 5 mg, one tablet by mouth one time a day. According to Lexi-comp (www.[NAME].com, a nationally recognized drug information resource), oxybutynin extended-release tablets must be swallowed whole with liquid; do not crush, divide, or chew. 4. Resident 21 was admitted on [DATE] and has an order for ER (extended release) Potassium (a type of supplements) Cl Crys, Klor-Con M20 Tablet. During an interview on 12/7/21 with Resident 21, Resident 21 stated licensed vocational nurse A (LVN A) has been crushing the potassium for at least a year. During an interview and subsequent observation on 12/9/2021 at 9:42 a.m. with LVN A, LVN A stated Resident 21 got Potassium. LVN A showed the medication packet to surveyor. The packet indicated do not crush. LVN A stated she crushed the tablets because Resident 21 wanted them crushed. During an interview on 12/9/2021 at 10:08 a.m., with LVN A, LVN A stated the medication push pack indicated not to crush, but it was resident preference. LVN A stated there was not a physicians order to crush the potassium medication, probably should have one. During a review of Resident 21's medication administration record (MAR) for 12/2021, the MAR indicated Klor-Con M20 Tablet Extended Release (Potassium Chloride Crys ER), Give 1 tablet by mouth in the morning for supplement (sic). Do not crush or chew. Ordered 11/1/2021 1355. During a review of Resident 21's physician order summary (orders), the orders indicated Klor-Con M20 Tablet Extended Release (Potassium Chloride Crys ER), Give 1 tablet by mouth in the morning for supplement (sic). Do not crush or chew. During a review of the facility's policy and procedure titled, Crushing Medications, revised 04/2018, indicated medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders .that the manufacturer states should not be crushed (for example, long-acting or enteric coated medications). a. The attending physician or consultant pharmacist must identify an alternative medication and/or dosage form; 5. Resident 48 was admitted to the facility on [DATE]. During a review of Resident 48's electronic records, there was no initial care plan dated as initiated within 48 hours of her admission. There was only a care plan dated 1/14/2021. During an interview on 12/9/2021 at 3:20 p.m. with medical records staff (MR), the MR stated the first care plan for Resident 48 was a discharge care plan, initiated on 1/14/2021. She was admitted on [DATE]. During a review of the facility's policy and procedure titled Care Plans - Baseline, revised 12/2016, indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fall management and interventions were evaluated and implemented to prevent further falls for four out of 18 sampled residents (Residents 36, 52, 54 and 283) when: 1. For Resident 36, neuro-checks (an evaluation to sensory and motor responses, reflexes to determine if the nervous system is impaired) were incomplete, interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) did not discussed falls, OT evaluation was not implemented, no new interventions were implemented after a fall, there was no physician order for the use of soft padded helmet, postural hypotension was not monitored. 2. For Resident 52, medication regimen review (MRR, process of comparing medication), no fall risk assessment, and no evidence an IDT was done after a fall. 3. For Resident 54, failed to follow care plan and physician order for the use of floor mat. 4. Resident 283, failed to provide assistance to two falls, fall care plan interventions was not specific for Resident 283's condition, did not have an IDT and rehabilitation therapy recommendation was not implemented after the second fall, and Fall Risk Assessment was not coded correctly. These failures resulted in repeated falls and had the potential to cause decline in the resident's physical function. Findings: 1. Review of Resident 36's clinical record indicated, she was admitted to the facility on [DATE] with diagnoses including dementia (memory loss) and repeated falls and history of falling. a. Review of Resident 36's Post-Fall Review dated 1/6/21 indicated Resident (36) was observed on the floor in her room. She stated she hit her head. Review of Resident 36's progress notes dated 1/6/21 indicated Resident (36) had an unwitnessed fall and large bump at the back of her head was noted and neuro check was initiated. Resident 36's clinical record did not indicate her fall on 1/6/21 was discussed by the IDT and there was no documentation neuro check was initiated. b. Review of Resident 36's Post-Fall Review dated 1/23/21, indicated she had a witnessed fall in the facility's lobby. Review of Resident 36's clinical record did not indicate her fall on 1/23/21 was discussed by the IDT and there was no documented neuro checks. During an interview with the minimum data set nurse (MDSN) on 12/9/21 at 1:56 p.m., the MDSN confirmed the fall on 1/6/21 and 1/23/21 were not discussed by the IDT. The MDSN further stated the fall should had been discussed within 72 hours by the IDT. During an interview with the MDSN on 12/10/21 at 1:49 p.m., the MDSN confirmed there were no neuro checks initiated for the falls on 1/6/21 and 1/23/21. c. Review of Resident 36's Post-Fall Review dated 1/24/21, indicated she had an unwitnessed fall in her room. Review of Resident 36's IDT notes dated 1/25/21 indicated resident was observed lying on the floor in her room. Resident was assessed and found a lump on the back of her head, skin appeared to have a laceration with small amount of bleeding noted. Resident (36) was transferred to a community hospital per family request. The IDT recommended an occupational therapy evaluation (OT, health care area that deals with rehabilitation through performing activities of daily living). Review of Resident 36's clinical record did not indicate an OT evaluation was done. During an interview on 12/9/21 at 4:44 p.m., the MDSN confirmed the OT evaluation was not done. d. Review of Resident 36's minimum data set (MDS, an assessment tool) dated 6/26/21, indicated Resident 36 had a fall without injury. Further review of Resident 36's clinical record did not indicate a post fall risk assessment was done. There was no change of condition notes and no post fall review or progress notes done. Review of Resident 36's IDT notes dated 4/27/21 indicated, she had an unwitnessed fall in the hallway. IDT recommended to continue neuro checks. Additional review of Resident 36's clinical record did not indicate a neuro check was done. During an interview with the MDSN on 12/9/21 at 2:56 p.m., the MDSN confirmed there were no post fall review, no progress notes and no change of condition notes for the fall in April 2021. e. Review of Resident 36's Post-Fall Review dated 7/26/21, indicated she had a witnessed fall in front of station AA. Review of Resident 36's neurological assessment flowsheet dated 7/26/21, indicated the assessments were incomplete. During a concurrent interview and record review with the MDSN on 12/10/21 at 9:47 a.m., the MDSN reviewed the above neurological flowsheet and confirmed it was incomplete. f. Review of Resident 36's Post-Fall Review dated 8/28/21, indicated she had a witnessed fall by station BB. Review of Resident 36's IDT notes dated 8/30/21 indicated the IDT recommended a soft padded helmet. During an observation in Resident 36's room on 12/8/21 at 8:10 a.m., there was a white helmet hanging at the front wheeled walker. Review of Resident 36's clinical record indicated there was no physician order for the use of the soft padded helmet. During a concurrent interview and record review with the MDSN on 12/9/21 at 2:16 p.m., the MDSN reviewed Resident 36's clinical record and confirmed there was no physician's order for the use of soft padded helmet. g. Review of Resident 36's Post-Fall Review dated 10/2/21, indicated she had an unwitnessed fall and was found on the floor in her room. Review of Resident 36's IDT notes dated 10/4/21 indicated IDT believes that given residents hx (history) of falls and impulsive behavior, dementia the event was unavoidable. IDT will continue to monitor resident and evaluate for new interventions if required. Review of Resident 36's neurological assessment flowsheet dated 10/2/21, indicated the assessments were incomplete. During a concurrent interview and record review with the MDSN on 12/10/21 at 9:47 a.m., the MDSN confirmed the neuro check assessment flowsheet was incomplete. h. Review of Resident 36's Post-Fall Review dated 10/8/21, indicated she had a witnessed fall in the dining room. Further review of Resident 36's clinical record did not indicate an IDT was done to address the fall. During a concurrent interview and record review with the MDSN on 12/9/21 at 2:27 p.m., the MDSN reviewed Resident 36's clinical record and confirmed there was no IDT done for the fall on 10/8/21. i. Review of Resident 36's Post-Fall Review dated 10/16/21, indicated she had an unwitnessed fall and was found on the floor in the hallway next to station AA. Review of Resident 36's IDT notes dated 10/18/21, indicated IDT has used all interventions, exhausted all possibilities. Will continue to monitor. During a concurrent interview and record review with the MDSN on 12/9/21 at 2:32 p.m., the MDSN reviewed the IDT notes dated 10/18/21 and stated there was no new intervention. j. Review of Resident 36's eInteract Change in Condition Evaluation V4.2 dated 10/24/21, indicated she was found on the floormat in a resident's room. Review of Resident 36's clinical record did not indicate a post fall review and a post fall risk assessment were done on the above fall. During an interview with the MDSN on 12/10/21 at 1:45 p.m., the MDSN confirmed there was no post fall risk assessment and no post fall review done for Resident 36's fall on 10/24/21. k. Review of Resident 36's Post-Fall Review dated 10/26/21, indicated she was found on her floormat inside her room. During a concurrent interview and record review with the MDSN on 12/9/21 at 1:46 p.m., the MDSN reviewed Resident 36's physician order dated 10/28/21, indicating to monitor orthostatic hypotension (low blood pressure when standing up, sitting, or lying down). On 12/9/21 at 4:46 p.m., the MDSN stated she could not find the orthostatic hypotension monitoring. Review of Consultant Pharmacist's Medication Regimen Review (MRR) dated 10/27/21, indicated the MRR was done after a fall, the report further indicated Please consider screen for postural hypotension at lying and standing position. Review of Resident 36's Post-Fall Review dated 11/24/21, indicated she had a witnessed fall in the dining room. Review of Resident 36's Post-Fall Review dated 12/2/21, indicated she had a witnessed fall. 2. Review of Resident 52's clinical record indicated she was admitted to the facility on [DATE], with diagnoses including repeated falls, unspecified dementia with behavioral disturbance. During a concurrent interview and record review on 12/10/21 at 10:12 a.m., with the MDSN, the MDSN reviewed Resident 52's clinical record and confirmed she had an unwitnessed fall on 7/6/21, witnessed fall on 7/12/21, an assisted fall on 7/13/21, an unwitnessed fall on 8/6/21 and a witnessed fall on 8/24/21. Review of Resident 52's eInteract change of condition dated 11/19/21, indicated she had an unwitnessed fall. During a concurrent interview and record review with the MDSN on 12/10/21 at 1:52 p.m., the MDSN reviewed Resident 52's clinical record and confirmed the resident had a fall on 11/19/21 and there was no post-fall review, no fall assessment after the fall and there was no IDT done. Review of Consultant Pharmacist's Medication Regimen Review dated 7/9/21, indicated the MRR was done due to Resident 52's falls. The MRR further indicated Please screen for postural hypotension at lying and standing positions. During an interview with the MDSN on 12/10/21 at 2:00 p.m., the MDSN reviewed Resident 52's clinical record and confirmed there was no order for postural hypotension and there was no postural hypotension monitoring done. During an interview with the consultant pharmacist (CP) on 12/10/21 at 2:44 p.m., the CP stated if the resident was ambulating and prone to falls, his expectations was for the facility to check postural hypotension. Review of the facility's policy, Change in a Resident's Condition or Status dated 2/2021, indicated A significant change of condition is a major decline or improvement in the resident's status that requires interdisciplinary review and/or revision to the care plan. Review of the facility's policy, Fall Risk Assessment dated 3/2018, indicated The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The attending physician and nursing staff will evaluate the resident's vital signs Review of the facility's policy, Falls and Fall Risk, Managing dated 3/2018, indicated If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. Review of the facility's policy, Charting and Documentation dated 7/2017 indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of Resident 54's admission record indicated he was admitted to the facility with a diagnosis including quadriplegia (paralysis that results in the loss of movement and sensation in all four limbs) and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Review of Resident 54's order summary report dated 8/21/19, indicated single floor mat r/t (related) poor safety awareness. Review of Resident 54's care plan dated 8/21/19, indicated Resident 54 was high risk for fall and his interventions included single floor mat r/t poor safety awareness. Review of Resident 54's post fall review dated 6/11/21, indicated he had an unwitnessed fall in his room trying to get out of bed. Review of Resident 54's Inter Disciplinary Team (IDT) review notes dated 6/14/21, indicated Resident 54 had skin tear to left forearm, left lateral ankle and lifted his great toe nails. During an observation on 12/7/21 at 9:36 a.m., 12/8/21 at 8:45 a.m. and, 12/9/21 at 9:10 a.m., Resident 54 was in lying in bed and there was no floor mat. During an interview with CNA B on 12/9/21 at 9:10 a.m., CNA B confirmed Resident 54 did not have a floor mat and he had previous falls. During an interview and concurrent record review with NS on 12/9/21 at 2:12 p.m., the NS reviewed Resident 54's IDT and it did not indicate Resident 54 had a floor mat in place during the fall. The NS acknowledged Resident 54's physician order and care plan were not implemented. 4. Review of Resident 283's admission record indicated he was admitted on [DATE], with a diagnosis including parkinson's disease (a movement disorder that causes tremors, stiffness, and slow movement), need assistance with personal care, dementia, repeated falls and history of falling. Review of Resident 283's admission/readmission data tool dated 11/5/21, indicated he was alert, needed two person physical assistance and complete assistance or mechanical assistance (e.g. Hoyer Lift) and under fall risk assessment, he was identified as at risk for falls. Review of Resident 283's MDS dated [DATE], indicated he has a BIMS of 7 (meaning cognitively impaired). He needed extensive assistance with two or more person physical assistance during bed mobility and transfer; extensive assistance with one person physical assistance during toilet use. His balance during transition and walking was not steady and only able to stabilized with staff assistance. Review of Resident 283's Fall Risk assessment dated [DATE], indicated he had multiple falls within the last six months, his medication use did not identified he was taking anti parkinson's medication, and he was identified as at risk for falls. Review of Resident 283's order summary report dated 11/ 5/ 21, indicated Carbidopa- Levodopa (a type of anti parkinson's medication) tab 25-100 mg one tablet p.o. (by mouth) at bedtime related to parkinsons disease and give 2 tablets by mouth before meals related to Parkinson's disease. Review of Resident 283's care plan dated 11/6/21, indicated Resident 283 was at risk for falls r/t Parkinson's and Parkinson's Dementia with hallucinations. His interventions initiated on 11/6/21 indicated Implement facility fall prevention protocol and notify MD (physician) if increase in falls. The fall care plan did not specify what type of fall prevention protocol needed to be in place. Review of Resident 283's Post Fall Review dated 11/5/21, indicated he had a fall on 11/5/21 at 5:20 p.m., seen falling on the floor in his room, ambulating and no slide/gripper socks. He was alert and oriented to person. Review of Resident 283's progress notes dated 11/5/21, indicated after multiple reminders to wait for a CNA within a five minute window, Resident 283 fell on the way to the bathroom. Resident fell while a CNA was entering the room to assist. During an interview with CNA L on 12/9/21 at 2:52 p.m., he stated he was not the assigned nurse for Resident 283 when he answered Resident 283's roommate call light. CNA L stated Resident 283 said he needed to go to the bathroom. Since Resident 283 was not trying to climb out of bed, CNA L exited the room to get some help because Resident 283 was pretty big. CNA L stated he was away between 3-5 minutes looking for help and when he returned, he saw Resident 54 on the floor. CNA L stated he did not know Resident 283's cognitive and functional level. Review of Resident 283's care plan dated 11/16/21, indicated Resident 283 placed himself on the floor from the wheelchair. His interventions included to request therapy to reevaluate the wheelchair and a wheelchair cushion. Review of Resident 283's physical therapy and occupational therapy treatment notes provided by the NS, indicated between 11/9/21 to 11/19/21, Resident 283 had therapy treatment. However, there was no evidence a re-evaluation of a wheelchair cushion was provided. Review of Resident 283's COC Evaluation dated 11/19/21, indicated he had a fall and sustained a bruise on top of scalp and left eye swelling. Review of Resident 283's Post Fall Review dated 11/19/21, indicated he had an unwitnessed fall in the hallway. Prior to fall, the review indicated Resident 283 was sitting in the wheelchair, attempted constantly to stand on his own and he was alert and disoriented. Review Resident 283's progress notes did not have an IDT review. His care plan dated 11/22/21, indicated intervention to apply dycem pad in the wheelchair. During an interview and concurrent record review with the NS on 12/8/21 at 8:56 a.m., he stated Resident 283's first fall on 11/5/21 was preventable, as Resident 283 needed assistance and CNA L should not have left Resident 283 unattended. The NS confirmed there was no IDT done after Resident 283's second fall on 11/19/21. During a follow-up interview with the NS on 12/10/21 at 9:21 a.m., he acknowledged Resident 283's fall care plan did not address the specific interventions with his multiple fall history. When the NS was asked what type of fall prevention protocols were in place by the facility specific for Resident 283. The NS was not able to provide protocol and stated the facility provided IDT review as part of the fall protocol. The NS confirmed Resident 283's Fall Risk admission assessment was incorrectly done and the therapy treatment did not include the re-evaluation of the wheelchair cushion. During an interview with the DON on 12/10/21 at 10:32 a.m., the DON stated part of the facility's nursing endorsement was done during a huddle, or change of shift. The DON stated he expected nurses to get information prior to providing care. The DON stated CNA L should have Resident 283 within his visual range while getting assistance. The DON acknowledged Resident 283 needed supervision such as providing a wheelchair alarm, closer to nurses station and Resident 283 visually in sight of nurses when Resident 283 was exhibiting behavior of constantly getting up prior to the second fall. Review of facility's policy, Fall and Fall Risk, Managing, dated 3/2018, indicated Based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk: the staff, with the input of attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .the position change alarms would not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. Review of facility's policy, Fall Risk Assessment , dated 3/2018, indicated Assessment data should be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis). Review of facility's policy, Care Plans, Comprehensive Person-Centered. dated 12/2016, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when: 1. Failed to obtain and administer warfarin (Coumadin, a medication that can treat and prevent blood clots) for atrial fibrillation (a-fib, an irregular heartbeat that can cause poor blood flow) for one of 18 sampled residents (Resident 71). 2. An opened refrigerated emergency kit was not replaced timely. The deficient practice resulted in Resident 71 not receiving seven scheduled doses of the medication in October, 14 doses in November and seven doses in December 2021. An e-kit not being replaced in timely manner could put residents needs not being met. Findings: 1. Review of Resident 71's clinical record indicated he was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including a-fib, dementia (memory loss) and unspecified psychosis (abnormal thinking and perceptions). Review of Resident 71's physician order dated 12/24/20, indicated warfarin 5 milligrams (mg, unit of measurement) one tablet by mouth in the evening every Monday, Tuesday, Wednesday, Thursday, Saturday and Sunday for a-Fib. Additional review of the physician order dated 12/24/20, indicated warfarin 7.5 mg one tablet by mouth in the evening every Friday for a-fib. A review of Resident 71's November 2021 medication administration record (MAR) indicated on November 7, 8, 10, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30 a total of 13 days his warfarin 5 mg medication was signed as 10 (10, chart code for other). Review of the November 2021 eMar-Medication Administration Note for the warfarin 5 mg medication indicated the following: 11/8/21-none on hand still in Order 11/10/21-on order 11/11/21- Cubex provided (cubex, an automated medication dispensing system) 11/20/21- on order 11/21/21- none on hand 11/22/21- on order physician notified. 11/23/21- on order 11/24/21-still on order 11/27/21- on order 11/28- on order 11/29/21- on order 11/30/21- on order Further review of Resident 71's MAR indicated, warfarin 7.5 mg 1 tablet every Friday was signed 10 on 11/26/21. The eMar note indicated none on hand. Additional review of Resident 71's December 2021 MAR indicated the following: Warfarin 5 mg 1 tablet was signed as 10 on 12/1, 12/2, 12/4, 12/5, 12/6, 12/7. The eMar-Medication Administration Note indicated the following: 12/1- none on hand 12/2- on order 12/4- on order 12/5- non on hand 12/6- none on hand 12/7- on order called pharmacy Resident 71's warfarin 7.5 mg 1 tablet every Friday was signed 10 on 12/3/21. The eMar-Medication Administration Note indicated the medication was on order. During an interview with the Doctor of Medicine (MD) on 12/9/21 at 3:06 p.m., the MD stated the pharmacy was not dispensing Resident 71's warfarin medication and the facility did not notify him. The MD further stated Resident 71's PT/INR (PT: prothrombin time/international normalized ratio, a test to determine the effect of Coumadin; it measures how long it takes, in seconds, for blood clot. The American College of Cardiology Physicians guidelines for Antithrombotic Therapy for the Prevention and Treatment of Thrombosis [clotting of the blood] recommends a therapeutic [target] INR range of 2.0 to 3.0 in patients receiving Coumadin for atrial fibrillation) on 12/9/21 was 1.1. The MD explained an INR of 1.1 puts Resident 71 at risk for stroke. The MD added the facility should have called him if the pharmacy did not dispense the medication because he was responsible for the resident's anticoagulation therapy (anticoagulants, use to treat blood clots). During a concurrent interview and record review with the minimum data set nurse (MDSN) on 12/9/21 at 4:57 p.m., the MDSN reviewed Resident 71's MAR and eMar notes and confirmed the resident did not receive his warfarin medication on multiple days. During an interview with the nursing supervisor (NS) on 12/10/21 at 7:59 a.m., the NS stated the MD had been responsible with Resident 71's anticoagulation therapy since 2019. The NS was asked about Resident 71's previous INR results, the NS stated he could not provide documented INR result because the MD did not make a progress notes regarding the previous INR result. Additional concurrent interview and record review with the NS on 12/10/21 at 8:12 a.m., the NS reviewed Resident 71's October 2021 MAR and confirmed the medication was not given on 10/10, 10/11, 10/18 to10/21 and 10/28, total of 7 days. The NS stated if the medication was not on hand, his expectation was for the licensed nurses (LN) to notify the physician and document the physician's response. If the attending physician (AP) did not respond, the LNs should follow-up the next day. The NS further stated his expectation was for the LNs to contact the pharmacy and document the pharmacy's response. Review of the October 2021 eMar notes provided by the facility indicated the following: On 10/10/21- medication is unavailable, reorder sent to pharmacy On 10/20/21- no medication on hand On 10/21/21- pharmacy has been notified about warfarin reorder On 10/28/21- none on hand The above eMar notes did not indicate the attending physician (AP) or the MD were notified regarding the medication not being given. There was no documentation provided regarding follow ups made to the pharmacy and or pharmacy's response. On 12/10/21 8:21 a.m., the NS stated the pharmacy had been made aware multiple times regarding Resident 71's warfarin medication because the pharmacy would not dispense the medication without the INR result. The NS stated the pharmacy was told Resident 71's INR test was being done in house by the MD. During an interview on 12/10/21 at 2:48 p.m., with the consultant pharmacist (CP), the surveyor informed the CP Resident 71's warfarin was not being given due to not being on hand in the facility. The CP stated he was not sure if the pharmacy was waiting for Resident 71's INR result. During an interview with licensed vocational nurse G (LVN G) on 12/13/21 at 11:21 a.m., LVN G stated she recently called the pharmacy regarding Resident 71's warfarin medication and was told the AP was the prescriber and it was not the MD. LVN G further stated she did not document the response of the pharmacy. LVN G stated if the medication was not available, the protocol was to call the pharmacy and if the pharmacy would not dispense the medication, the next step was to notify the physician. During an interview with the [name of the pharmacy] pharmacist on duty (POD), on 12/13/21 at 11:36 a.m., the POD stated additional information was needed so that they can investigate the reason Resident 71's warfarin was not delivered to the facility. During an interview on 12/13/21 at 12:34 p.m., the NS stated he did not see a current fax re-order of the medication. The NS stated the medication was being ordered through electronic [name of the system]. He further added, if there were only 5 tablets left, his expectation was for the LNs to reorder the medication. During an interview with the CP on 12/13/21 at 12:56 p.m., the CP stated he was not aware Resident 71 did not receive his doses of warfarin medication. The CP further stated he usually asked the facility the reason the medication was not given and if it was not on hand, he would check with the nurses when they last contacted the pharmacy. During an interview on 12/13/21 at 1:39 p.m., with the director of nursing (DON), the DON stated he was informed by the pharmacy that six tablets of the warfarin 5 mg and two tablets of the warfarin 7.5 mg were delivered on 11/12/21. There was no delivery manifest (delivery receipt or delivery list documentation) provided. Review of Resident 71's November and December 2021 MARs indicated he did not receive the 5 mg of warfarin from 11/20/21 to 12/7/21 and did not receive the 7.5 mg of warfarin on two consecutive Fridays on 11/26/21 and 12/3/21, when they were due. Review of the facility's policy Medication Ordering and Receiving From Pharmacy dated April 2008, indicated Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. The policy indicated, medication that are not automatically refilled by the pharmacy, reorder medication five days in advance of need to assure an adequate supply is on hand. If needed before the next regular delivery, inform pharmacy of the need for the prompt delivery. The emergency kit or emergency drug supply as applicable is used when the resident needs a medication prior to pharmacy delivery. 2. During an observation of Medication Room A on 12/6/21 at 9:16 a.m. with the infection preventionist (IP), there was a medication refrigerator with an emergency kit (E-kit, container of emergency medications) inside. The E-kit had yellow tabs. During a concurrent interview, the IP stated yellow tabs indicate the E-kit was opened to obtain a medication. During an observation and interview on 12/6/21 at 9:30 aeans.m., the IP opened the E-kit and stated the form indicated the E-kit was opened on 10/31/21 and has not been replaced. During an interview on 12/6/21 at 9:35 a.m., the IP stated the emergency kit should be reordered immediately. Review of the Emergency Kit Pharmacy Log found in the E-kit indicated, a vial of lispro (insulin, medication used to lower blood sugar) was removed from the E-kit on 10/31/21. Review of the facility's policy, Medication Ordering and Receiving from Pharmacy, dated 8/2014, indicated the following: when an emergency dose of medication is needed, the nurse unlocks the container and removes the required medication; after removing the medication, complete the emergency e-kit slip and re-seal the emergency supply; as soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the emergency drug supply.

Based on observation, interview, and record review the facility failed to ensure palatability and safety of cooked foods was maintained when pureed food was runny. These failures had the potential to impact all 19 residents on pureed diets in that it could result in a choking hazard (airway blocked by food), aspiration risk (when food or drink goes into the airway), and decreased palatability which could result in decreased intake and weight loss out of a facility census of 90. Findings: In an observation and interview on 12/6/2021 at 11:57 a.m., indicated [NAME] 1 plated food for resident lunches. He placed pureed food on the plates which went on the cart to serve then he added a powder to the pureed meat and mixed it up. He stated he added thickener because the meat was runny. After [NAME] 1 added the thickener to the pureed meat, the consistency was still very thin. It was noted that all the pureed diet tickets read Puree level 4. During observation and interview with the Registered Dietitian (RD), of the plating of the pureed food for lunch on 12/6/2021 at 12:02 p.m., it was observed the carrots and the meat were runny, spread out on the plate so it was flat, touching one another, and not the same consistency as other food items on the plate, including the pureed pasta and the pureed bread which was more of a mound shape on the plate. In addition to being runny, the meat separated so there was a clear liquid that spread out on the plate. The RD stated the carrots and meat varied in texture from the other food on the pureed plate and that the meat was very runny. The pureed carrots and pureed meat were runny, did not hold shape on the plate, and ran together on the plate. The RD stated there was a safety risk with runny pureed items and confirmed the risk was choking or aspiration. During observation on 12/7/2021 at 12 :34 p.m., of the pureed food plated for residents, the pureed ham, pureed mixed vegetables, and the pureed sweet potatoes were runny, not holding their shape, and ran into the other foods on the plate. Review of the facility document titled Dysphagia Diets Puree IDDSI [International Dysphagia Diet Standardization Initiative] Level 4 dated July 2019, showed the Puree Level 4 diet texture is to hold its shape on a plate. Also, any liquids must not separate from the food and the food can fall off a spoon intact. The food is more easily swallowed and prevents aspiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an initial tour observation in room CC on 12/6/21 at 9:14 a.m., there were used gloves near the clean linens. During a concurrent observation and interview with the director of nursing (DON) on 12/6/21 at 9:19 a.m., the DON confirmed the above observation and stated the used gloves should not be near the clean linen. 3. During an observation in room DD on 12/6/21 at 11:41 a.m., the privacy curtain had a whitish discoloration. During a concurrent interview with certified nursing assistant Q (CNA Q), she confirmed the above observation and stated the curtain should had been changed. 4. Review of Resident 282's admission record indicated he was admitted on [DATE] with a diagnosis including chronic obstructive pulmonary disease (COPD, a lung disease). During an observation and concurrent interview with LVN J on 12/6/21 at 12:39 a.m., Resident 282's oxygen tank had an oxygen tubing that was loose and has not covered. LVN J confirmed it should have a cover . Review of the facility's policy, Personal Protective Equipment - Using Gloves, dated 9/2010, indicated to discard used gloves into waste receptacle inside the examination or treatment room. Based on observation, interview, and record review, the facility failed to ensure staff implemented the infection control practices when: 1. Licensed vocational nurse G (LVN G) brought a medication to Resident 132's bedside and handled the medication bottle with used gloves; 2. There were used gloves near the clean linen in room CC; 3. The curtain in room DD had a whitish discoloration; and 4. Oxygen tubing for Resident 282 was left uncovered . These failures had the potential to result in transmission of infection in the facility. Findings: 1. Review of Resident 132's clinical record indicated he had a jejunostomy tube (J-tube, tube placed through the skin into the small intestine for medication or nutrition). Resident 132 had an order for omeprazole (medication used to treat heartburn) suspension 20 milligrams (mg)/10 milliliters (ml) two times a day via J-tube. During an observation on 12/7/21 at 4:01 p.m., LVN G took Resident 132's bottle of omeprazole from the medication cart and placed it on Resident 132's bedside table (the bottle was inside a plastic bag). LVN G put on gloves and handled Resident 132's J-tube when checking for proper placement. After handling the J-tube, LVN G did not change gloves. LVN G used the same gloves to open the plastic bag to uncover the bottle of omeprazole. LVN G opened the bottle and took a syringe and inserted it into the top of the bottle. During an interview on 12/7/21 at 4:24 p.m., the infection preventionist (IP) stated LVN G should not have brought the medication into Resident 132's room. When asked if LVN G should have changed gloves prior to handling the medication, the IP stated that it should not have happened to begin with.

Based on observation, interview, and record review the facility failed to ensure the competency of the two of two staff, the Registered Dietitian (RD) and the Dietary Services Supervisor (DSS), responsible for oversight of Food and Nutrition Services, when: 1. The RD did not provide consultation to the DSS regarding multiple kitchen sanitation issues (cross-reference F812); 2. The RD did not provide consultation regarding the palatability and consistency of food texture; 3. The DSS did not report multiple maintenance issues she was aware of including: a. a leaking reach-in refrigerator; and b. a reach-in freezer with significant ice build-up, 4. The DSS did not have a reliable system for ensuring staff cleaned according to the cleaning schedule; 5. The DSS and the RD did not ensure the juice machine was maintained in a clean and sanitary manner. 6. The DSS and the RD did not ensure sanitary handling of drinking ware, utensils, and ready to eat food. These failure had the potential for the functions of the Food and Nutrition Service not to be carried out in a safe and sanitary manner; in manner to provide food prepared by methods that conserved nutritive value, flavor, and appearance; and in a manner for food prepared in a form to meet the needs of residents, for 90 residents who received food from the kitchen. Findings: 1. Review of the document titled Orientation, Inservice, & [and] Personnel Management dated 2018, showed the consultant RD provided oversight of the operations of the Department of Food and Nutrition Services. One of the responsibilities included monitoring and recommending food service standards for sanitation, safety, and infection control. Review of the document titled Agreement to Provide Consultant Services signed 5/17/2019, showed a couple of the consultant dietitian's responsibilities included to review sanitation in accordance with current regulatory standards and to provide written reports of each visit to the facility including audits performed, summary of performance, goals, and recommendations. During observations from 12/6/21 to 12/12/21, multiple sanitation issues in the kitchen (cross-reference F812) included: the wood shelving under a preparation table was dirty and in poor condition; cooking pans ready for use had a significant amount of residue build-up, were significantly scratched on the cooking surface, and had non-stick coating peeling off; the floor area around a reach-in refrigerator and under a preparation table had a significant amount of residue build-up and cobwebs; knives for food preparation residue on the blades, the blades came into contact with dirty wire covers and were stored directly under an insect killer machine which had a fly on the surface; a significant amount of grime was in the grooves of the rubber gaskets (a rubber seal that on the door of the refrigerator to prevent leakage of cold from inside the refrigerator when the door is closed) of 2 refrigerator doors; the light switch into the dry food storage had residue build-up and had dirty tape on the surface; the wall in the dish machine area had black residue build-up; baseboard tiles were in bad repair and pulling away from the wall with grime between the tile and the wall; a counter mounted, industrial can opener had a significant amount of rust and residue build-up on the surface and the blade was in poor condition; a standing mixer bowl had rust on the inside surface; shelves in a beverage refrigerator were rusted; cutting boards stored ready for use had residue on the surface; and a drain cover in a food preparation sink was rusted. Review of the last three untitled documents, the RD used as a tool to inspect the kitchen, were dated 8/21/21, 9/30/21, and 10/29/21. The inspection documents included two pages of safety and sanitation items the RD could check off as Met or Not Met. There was also a column provided for comments. The inspection list included but was not limited to refrigerators and freezers are clean inside and outside, the kitchen work areas are clean and organized, cross contamination prevention in place, shelves, floors, walls, and ceilings are clean, dish machine area is clean, pots and pans area clean, dishes are free of stains, and food preparation utensils and equipment is cleaned properly and sanitized. All of these areas were marked as met on all three inspection dates. Also, no comments were made on any of the documents. In an interview on 12/8/21 at 2:40 p.m., the RD stated she did monthly audits of the kitchen. She stated the DSS did not like her to document issues on her report. The RD stated she did not observe build-up of grime in the kitchen such as the thick sludge residue at the base of the dairy refrigerator, she did not observe rust on the beverage refrigerator racks, she did not observe ripped rubber gaskets on the doors of the beverage refrigerator, she did not observe rust on the can opener, she did not notice tiles coming off the wall near the near the inside kitchen front door. She stated she thought the kitchen might be a little dirty, but it was old. She stated she did not report any cleanliness issues in any of her reports. She stated she was not concerned with a rusty drain cover inside the food preparation sink. She also stated her reports were provided to the Administrator and the Director of Nursing. In an interview on 12/9/21 at 2:15 p.m., the RD stated the DSS tended to limit the time she had to do the audit in the kitchen to about 30 minutes and she felt like she could use at least 45 minutes to an hour to do the audits. 2. During observation from 12/6/21 to 12/12/21, one resident complained about the food and there was bland, overcooked food, as well as pureed food that was not the appropriate consistency. (Cross-reference F804 and F805). Review of the PO [by mount] Diet Roster showed all pureed diets provided were Puree Level 4. In an interview on 12/6/21 at 12:04 p.m., the RD stated if pureed food was too runny, it could be an aspiration (breath in food to the lungs) risk and the resident could choke. She stated the pureed food should be a drop consistency. An observation and concurrent interview with the RD and the DSS on 12/7/21 at 3:30 p.m., indicated a Diet Manual approval dated on 2/14/19 and located in the DSS office area. The diet manual contained a description of various therapeutic diets including diets with modified consistency. The index did not show Puree Level 4 but did other texture modified diets including Pureed National Dysphagia (Difficulty or discomfort in swallowing, as a symptom of disease) Diet (NDD) Level 1, Dysphagia Mechanical Altered NDD Level 2, Dysphagia Advanced Diet NDD Level 3. On page 12 of the diet manual under the title Mechanically Altered/Texture Modified Diets it showed Mechanically altered foods are available for residents with chewing and/or swallowing problems .The Dysphagia diets are specifically for residents with swallowing problems .An evaluation team of speech-language pathologist/speech therapist, physician and registered dietitian will discuss the recommendation and obtain a physician's order for diet and texture appropriate for the resident .[Name of the menu service company] provides four levels of mechanically altered diets on the Menu Spreadsheets. They are as follows: Puree (Dysphagia Blenderized, NDD level 1); Mechanical Soft Ground; Dysphagia Mechanical Altered (NDD level 2); and the Dysphagia Advanced (NDD level 3) which is offered only in some states. The RD stated she was not sure why puree level 4, provided at the facility was not in the diet manual. She stated she had to ask the DSS about why this diet was not in the diet manual. The DSS looked through the diet manual and stated she could not find puree level 4. The DSS went to her office and returned with a document titled Dysphagia Diets Puree IDDSI level 4. Review of the document titled Dysphagia Diets Puree IDDSI [International Dysphagia Diet Standardization Initiative] Level 4 dated July 2019, showed the food on this diet holds it shape on a plate .Any liquids must not separate from the food and the food can fall off a spoon intact. The Food is more easily swallowed and prevents aspiration. In an interview on 12/8/21 at 2:40 p.m., the RD stated she did not observe tray-line and she generally did not include tray-line as part of her audit. She also stated she did not look to see if staff were following recipes when cooking food. (Cross-reference F802) In an interview on 12/10/21 at 10:18 a.m., the RD stated drop consistency meant if the food was on a spoon, it doesn't drop, kind of have to flick it off. To remind the RD what the pureed food looked like on the plate served for lunch on 12/6/21, the RD was shown photographs of the pureed food. The photo showed pureed carrots and pureed meet spread out flat over the surface of the plate and ran into the food items on the plate. Also, the pureed meat had a clear liquid that separated from the food. The photo also showed a scoop of pureed pasta, which held its shape in a mound formation, and a scoop of pureed bread that spread slightly but held a mound shape. The RD stated the foods that had the appropriate consistency for a level 4 puree diet were the carrots and the meat. She stated the pureed pasta and pureed bread were thicker than the carrots and meat and maybe too thick because they held their shape. Review of the document titled Orientation, Inservice, & [and] Personnel Management dated 2018, showed the RD provided oversight of the operations of the Department of Food and Nutrition Services. A couple of the responsibilities of the consultant RD were to monitor and recommend food service standards for safety, also to evaluate and monitor the food service department to assure that the department was providing adequate, acceptable quality food. 3. During observation from 12/6/21 to 12/12/21 equipment was not maintained. This included a reach in refrigerator the facility used to store dairy products, which the DSS stated was leaking and causing the significant amount of residue build-up at the base of the refrigerator and a reach-in freezer with a significant amount of ice build-up inside. (Cross-reference F908) Review of the undated job description titled Dietary Supervisor showed the DSS was responsible for ensuring food service equipment was clean and operable. a. In an interview and observation on 12/6/21 at 9:10 a.m., during the initial tour of the kitchen. the dairy refrigerator had a significant amount of brown, sticky residue build-up at the bottom, front of the refrigerator. The DSS stated the residue was rust because the refrigerator leaked. She stated she reported the leak to maintenance. In an interview on 12/6/21 at 12:32 p.m., the DSS stated she verbally told maintenance about the ice build-up last week, but she did not have documentation. In a telephone interview on 12/9/21 at 9:23 a.m., the pest control technician stated he serviced the facility kitchen on the evening of 12/7/21 due to a report of small flies. He stated the most likely breeding place for the flies was under the dairy refrigerator because there was a lot of dampness under this refrigerator and also a lot of gook. (Cross-reference F925) In an interview on 12/10/21 at 9:54 a.m., the DSS stated when the refrigerator leaked, staff dried it off. She stated it leaked on the floor in the front of the refrigerator. She stated the refrigerator did not move so they were not able to clean under it. She stated it was leaking since October. In an interview on 12/10/21 at 11:01 a.m., Maintenance Supervisor E (MS E) stated he was not made aware of the leaking dairy refrigerator until after it was observed by the surveyors on 12/6/21. b. In an interview and observation on 12/6/21 at 9:10 a.m., during the initial tour of the kitchen, the reach-in freezer had a significant amount of ice build-up on the freezer ceiling and chunks of ice on the freezer floor. In an interview on 12/6/21 at 12:32 p.m., the DSS stated she verbally told maintenance about the ice build-up last week, but she did not have documentation. In an interview on 12/6/21 at 2:15 p.m., MS E stated he did not remember the DSS reporting the ice-build up in the freezer. An observation and interview on 12/7/21 at 10:40 a.m., indicated ice build-up inside the reach-in freezer on the ceiling surface and pieces of ice on the freezer floor. The freezer also had a significant amount of condensation on the outside surface around the freezer doors. The DSS stated she was not really concerned about the ice build-up because the ice pieces were not big. Review of the invoice dated 12/7/21, indicated a technician serviced the reach-in freezer and stated the ice-build up was due to the freezer being too full of boxes stacked to the top which did not allow good air circulation. 4. Review of the undated job description titled, Dietary Supervisor indicated the DSS was responsible for monitoring staff to confirm they adhered to all sanitation, safety, and procedural guidelines within the department, ensuring food service equipment was clean. During observation from 12/6/21 to 12/12/21, multiple sanitation issues were in the kitchen (cross-reference F812). This included the wood shelving under a preparation table was dirty and in poor condition; cooking pans ready for use had a significant amount of residue build-up, were significantly scratched on the cooking surface, and had non-stick coating peeling off; the floor area around a reach-in refrigerator and under a preparation table had a significant amount of residue build-up and cobwebs; knives for food preparation residue on the blades, the blades came into contact with dirty wire covers, and were stored directly under an insect killer machine which had a fly on the surface; a significant amount of grime was in the grooves of the rubber gaskets (a rubber seal that on the door of the refrigerator to prevent leakage of cold from inside the refrigerator when the door is closed) of 2 refrigerator doors; the light switch into the dry food storage had residue build-up and had dirty tape on the surface; the wall in the dish machine area had black residue build-up; baseboard tiles were in bad repair and pulling away from the wall with grime between the tile and the wall; a counter mounted, industrial can opener had a significant amount of rust and residue build-up on the surface and the blade was in poor condition; a standing mixer bowl had rust on the inside surface; shelves in a beverage refrigerator were rusted; cutting boards stored ready for use had residue on the surface; and a drain cover in a food preparation sink was rusted. In an interview and observation on 12/6/21 at 12:32 p.m., the surface of the shelving under the preparation table that held the coffee machine, was covered with residue and grime. (Cross-reference F812) The DSS stated the shelving was not clean and this area was not on the cleaning schedule. In an interview and observation on 12/6/21 at 2:28 p.m., the rubber gaskets around the beverage refrigerator doors were imbedded with brown grime and what resembled food crumbs. The DSS stated the rubber gaskets were not on a cleaning schedule and when they [referring to kitchen staff] get a chance they will clean. In an interview on 12/7/21 at 10:13 a.m., the DSS showed a cleaning schedule attached to the outside of a refrigerator door. The schedule listed multiple tasks listed by day and staff job position. When the DSS was asked how she verified the cleaning was done according to the schedule she stated, sometimes they sign-off, sometimes staff will clean on a different day other than what's shown on the schedule, sometimes I have someone else clean. 5. An observation and concurrent interview with the DSS and Kitchen Staff 1 (KS 1) on 12/6/21 at 10:09 a.m., showed a juice machine with the juice gun submerged in a picture of water. The water was pink. The juice gun had a white, slimy residue between the buttons. Also, the tubing that connect the juice syrup bags to the machine were sticky feeling with fuzzy residue stuck to the surface of the tubing. The DSS stated a juice machine company came to clean the juice machine. She stated she thought they came quarterly. She also stated the cleaning of the juice machine was not assigned to any staff, indicating anyone could clean it. KS 1 demonstrated how he cleaned the machine. He wiped the juice gun with a rag that was soaked in a quaternary ammonia (a sanitizer) solution. Then he ran the juice gun holder through the dish machine. The DSS stated the juice gun was soaked in a pitcher of hot water about every other day. In an interview on 12/7/21 at 11:36 p.m., the DSS stated she did not have instructions for cleaning the juice machine or the manufacturer's manual for the machine. In an interview on 12/8/21 at 2:40 p.m., the RD stated she did monthly audits of the kitchen. She stated she did not look at the juice machine during her audits. In an interview with Maintenance Supervisor E (MS E) on 12/9/21 at 1:30 p.m., he stated he did not have invoices to show the juice machine company came out to clean the machine and they did not come out on a regular scheduled bases for cleaning. He stated the only times they serviced the juice machine was when he called them because something was wrong with the machine. In an interview with the DSS on 12/9/21 at 2:40 p.m., the DSS stated the current juice machine company did not come out for cleaning of the juice machine, but they should. She stated the last juice machine company came out for regular cleaning, but they started using a different juice machine company. She stated she did not know when this change happened. She stated she did not provide any training to her staff about how to clean the machine. Review of an e-mail document with the subject title RE: Cleaning instructions for the [brand of the juice machine] bar gun dated 12/10/21 and a concurrent interview with MS E on 12/10/21 at 11:35 a.m., showed the dates the company were at the facility and what they did when they serviced the juice machine. On 8/31/2020, the juice machine unit was installed. On 9/17/2020, 10/12/2020, 11/17/2020, and 3/9/2020, the company came out to fix the juice machine. MS E stated there was no cleaning by the company on these dates. On 7/7/21, the e-mail showed the juice machine was leaking so the technician replaced the oring [O-ring; a mechanical seal in the shape of a ring placed between two parts to make a seal] and fittings and cleaned the bar gun. MS E stated the cleaning of the bar gun by the company on 7/7/21 was the only cleaning documentation he had. Review of the undated manufacturer's manual for the juice machine titled [Name of juice machine] Post-mix Beverage Dispenser showed detailed instructions for cleaning. It showed the cleaning solution to use was [Brand name] Chloromelamine (a sanitizer). The preparation of the solution included adding two packets of Chloromelamine sanitizer powder to 5 gallons of warm potable water in a clean 5-gallon bucket. This produces a 100 part per million (ppm; sanitizer strength) chlorine solution. The instructions indicated other chlorinated sanitizers other than [Brand name] could be used and follow instructions to make it a 100 ppm solution. The manual showed detailed instructions for cleaning the Sheathing (a protective case or cover). The instructions for cleaning the nozzle included a cup of the cleaning solution. Then grasp the nozzle and twist back and forth while pulling the nozzle away from the handle. If the nozzle is difficult to remove, immerse nozzle end of the handle in a cup of carbonated water for five minutes before attempting removal again. When the nozzle is removed, place in cup of cleaning solution for 2 minutes. Immerse a clean brush in the sanitizer solution. Scrub nozzle and diffuser with a clean brush until any and all buildup is removed. Then remove the nozzle from the cleaning solution and allow the nozzle and diffuser to air dry. Then reinstall the nozzle onto the diffuser. The manual also gave detailed instruction for cleaning the Post-Mix System which involved filling a sanitizer tank and disconnecting all the connectors to the bags of syrup. Then connect the connectors to the sanitizing tank. The directions showed the sanitizing steps were followed by detailed rinsing steps. During a record review of the facility's policy, Sanitization, revised October 2008, indicated all areas of the kitchen should be kept clean. Review of the document titled Orientation, Inservice, & [and] Personnel Management dated 2018, showed the consultant RD provided oversight of the operations of the Department of Food and Nutrition Services. One of the responsibilities included monitoring and recommending food service standards for sanitation, safety, and infection control. Review of the undated job description titled Dietary Supervisor indicated the DSS was responsible for supervising and training dietary staff, as well as monitoring staff to confirm they adhere to all sanitation, safety, and procedural guidelines within the department. The DSS was also responsible for ensuring food service equipment was clean and operable. 6. An observation and concurrent interview with the DSS on 12/2/21 at 12:30 p.m., showed KS 1 placed items on trays for resident lunches included plastic cups filled with a beverage, utensils, and salads. KS 1 did not wear gloves. The cups with beverages were covered with plastic lids. When he handled the cups, he grabbed the very top so his fingers came into contact with the area a person would put their mouth to drink. When KS 1 handled the utensils, his hands came into contact with the end of the utensil that a person would put in their mouth. The salads KS 1 placed on the trays were in uncovered bowls. He handled the salads by placing his hand over the top of the salad and grabbing the top of the bowl, so the palm of his hand came into contact with the lettuce in the bowl. The DSS stated she did not see a problem with the way KS 1 handled the cups, utensils, and salads. She asked what the difference was between wearing gloves or using bare hands to touch the items. In an interview on 12/8/21 at 2:40 p.m., the RD stated she did monthly audits of the kitchen. She stated she did not observe tray-line food service or watch for hand hygiene when she did her audits. Review of the facilities policy and procedure, Glove Use dated 2017, indicated single use gloves must be worn if bare hands are to contact ready-to-eat food. According to the 2017 Federal Food Code, clean utensils shall be handled so that contamination of food-and lip-contact surfaces is prevented. Knives, forks, and spoons that are not prewrapped shall be presented so that only the handles are touched by employees. Review of the document titled Orientation, Inservice, & [and] Personnel Management dated 2018, showed the consultant RD provided oversight of the operations of the Department of Food and Nutrition Services. One of the responsibilities included monitoring and recommending food service standards for sanitation, safety, and infection control. Review of the undated job description titled Dietary Supervisor showed the DSS was responsible for supervising and training dietary staff, as well as monitoring staff to confirm they adhere to all sanitation, safety, and procedural guidelines within the department.

Based on observation, interview, and record review the facility failed to ensure palatability and nutritive value of cooked foods were maintained when vegetables were cooked for an extended time. In addition, one resident (Resident 78) complained about food being overcooked. This failure had the potential to result in decreased palatability; leading to a decrease in food consumed by residents, and food cooked for extended time periods could lose nutritive value leading to a decreased nutrient intake for 90 residents who received food from the kitchen. Findings On 12/6/2021 at 9:21 a.m., during an observation and interview with [NAME] 1 and Dietary Services Supervisor (DSS), indicated pans in a hot oven covered with foil. [NAME] 1 stated the items in the oven were pureed meat and pureed vegetables cooking in the oven for lunch time. DSS stated the meat and vegetables were already cooked and fully heated and ready to place on the tray line that started at 11:45 a.m. [NAME] 1 and the DSS stated the vegetables were in the oven since 9:00 a.m. The DSS stated this is their kitchen's practice to prepare purees early and continue to hold in the oven until lunchtime. During an interview with the facility's Registered Dietician (RD), on 12/6/2021 at 12:07 a.m., the RD stated food held in the oven for hours can affect the nutrients, especially the vegetables. During an observation and interview with the RD, on 12/7/2021 at 12:38 p.m., a sample test tray was requested due to residents complainting about the food was not good. Both the regular and puree diet were provided for tasting. The regular and the puree vegetables lacked flavor. Also, the regular vegetables were mushy and overcooked. During an interview with [NAME] 2 on 12/7/2021 at 12:45 p.m., [NAME] 2 stated she prepared the vegetables by taking the vegetables out of the box and placed them in the oven in a covered pan. She said the only ingredient she added to the vegetables was butter. [NAME] 2 stated she prepared them and put them in the oven at 10:00 a.m. [NAME] 2 stated she cooked the vegetables for 35 minutes and left them in the oven until the tray line food service started at 11:45 a.m. Review of the recipe, titled Capri Blend Veg dated 2002-2021, for provided for the vegetables prepared for lunch on 12/7/21, showed ingredients in addition to the vegetables and butter included salt, granulated garlic, and black pepper. The directions showed to steam the vegetables using pressure or without pressure. Using pressure steaming from 1 minute to 12-15 minutes. Without using pressure, the vegetables were to cook for 5-7. The recipe stated, Vegetables should be slightly crisp. The recipe showed to puree they prepared vegetables for the pureed diet. It was noted that [NAME] 2 did not use a steamer and did not use pressure to cook the vegetables. According to the Academy of Nutrition and Dietetics at Eatright.org, short cooking times help vegetables keep their bright color and crisper texture. When steaming vegetables, nutrients can get lost to the liquid. Also, heat can destroy B vitamins and vitamin C, so shorter cooking times help retain nutrients as well as crisp textures. During an interview on 12/6/2021 at 2:44 p.m., with Resident 78, Resident 78 stated he did not like the food. When asked what was the problem with the food, Resident 78 stated the cooks are the problem with food. Resident 78 elaborated by stating much of it was overcooked, sometimes undercooked, and it was not hot.

Based on observation, interview, and record review the facility failed to ensure food was stored, prepared, and served in a sanitary manner when: a. The wood shelving under a preparation table was dirty and in poor condition; b. Cooking pans ready for use had a significant amount of residue build-up, were significantly scratched on the cooking surface, and had non-stick coating peeling off; c. The floor area around a reach-in refrigerator and under a preparation table had a significant amount of residue build-up and cobwebs; d. Knives for food preparation had residue on the blades, the blades came into contact with dirty wire covers, and were stored directly under an insect killer machine which had a fly on the surface; e. A significant amount of grime was in the grooves of the rubber gaskets (a rubbers seal that on the door of the refrigerator to prevent leakage of cold from inside the refrigerator when the door is closed) of two refrigerator doors; f. The light switch into the dry food storage had residue build-up and had dirty tape on the surface; g. The wall in the dish washer area had black residue build-up; h. Baseboard tiles were in bad repair and pulling away from the wall with grime between the tile and the wall i. An industrial mounted can opener had a significant amount of rust and residue build-up on the surface and the blade was in poor condition; j. A standing mixer bowl had rust on the inside surface; k. Shelves in a beverage refrigerator were rusted; l. Cutting boards stored ready for use had residue on the surface; m. A drain cover in a food preparation sink was rusted; n. no air gaps (a gap in a drainpipe, from a piece of equipment that drains water, to the flood level rim of a floor ;drain or plumbing equipment) to an ice machine drainage or to the food preparation sink in the kitchen; o. There was expired food stored in the dry storeroom available for use and p. A peanut butter container was not clean on the outside. These failures had the potential to cause cross-contamination of food, pest infestation, and utensils for eating, leading to food-borne illness and/or illness from contaminated eating utensils for 90 residents who received food from the kitchen. Findings: Review of the facility's policy, titled Safety and Sanitation, revised 2017, showed spills will be cleaned up as they occur, storage areas will be kept clean, shelving will be kept clean, and floor are to be kept free of broken tiles. Review of the facility's policy, titled Sanitization, dated October 2008, indicated the kitchen areas shall be kept clean; all utensils, equipment, counters, and shelves shall be kept clean and maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning; seals will be kept in good repair; all equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils, kitchen surfaces not in contact with food should be cleaned regularly on a schedule to prevent the accumulation of grime. a. During an observation on 12/6/2021 at 9:57 a.m., the shelving under the preparation table where the coffee station was located, was in bad repair. The shelves were lined with plastic trays and on top of the plastic trays were empty food storage containers ready for use. The wood on the front edges of the shelving, especially along the bottom length of the shelving area, close to the floor, exposed particle board. There was also peeled and chipped paint along the front surface of the shelving. In addition, the shelving surface where the plastic trays and food bins were stored had a significant amount of food crumbs and/or food debris. There was also dried, brown, residue on the shelving surface that looked like dried liquid. In an interview on 12/6/21 at 12:32 p.m., the dietary services supervisor (DSS) stated the shelving under the coffee area was not clean and the area was not on a cleaning schedule. She confirmed the frame of the wood shelving along the floor was in bad repair. According to the 2017 Federal Food Code, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. b. During an observation and concurrent interview on 12/6/2021 at 9:27 a.m., with the DSS, three large skillet pans had significant black residue buildup on the inside cooking surface, two skillets had dried residue on the inside cooking surface that resembled food residue, and two small skillets had scratches and residue that covered the entire cooking surface and had a coating that was peeling off. One medium sized skillet had a significant number of scratches and orange residue on the inside cooking surface. The skillets were all hanging above the three-compartment sink. The DSS confirmed the pans had residue and scratches. She also stated the pans were ready to be used for food preparation. c. During an observation and concurrent interview on 12/6/2021 at 9:42 a.m., with the DSS, an area under a food preparation table, located between the dairy refrigerator and the food preparation sink, had plastic racks on the floor with cardboard boxes on top of the racks. The cardboard boxes contained disposable plastic lids and aluminum lids. The plastic crates holding the boxes had cobwebs in the grooves. A concurrent observation indicated the dairy refrigerator was sitting directly on the floor with an attached ramp, so a cart could be rolled inside. There was a groove between the ramp and the inside of the refrigerator that had brown residue imbedded. Also, at each side of the ramp area there was thick, orange, black, and brown colored residue. The residue was removable with a paper towel and was sticky and moist. Inside the dairy refrigerator, there was a white substance that covered the surface of the floor. The DSS confirmed there were cobwebs on the plastic crates under the food preparation table. She stated if there were spider webs, then we likely have spiders. She also confirmed the area at the base of the dairy refrigerator had black, orange and brown color grime. The DSS stated the thick residue was rust because the refrigerator leaked. She stated housekeeping scrubbed the floors once a month which included cleaning the floors under the food preparation sink and around the dairy refrigerator. She stated there was no cleaning schedule for staff to clean these areas. The DSS stated the white residue on the floor inside was from a spill. She stated the inside of the refrigerator was cleaned on Tuesdays, but staff should have cleaned the spill when it happened. In an interview and observation on 12/7/21 at 11:09 a.m., the house keeping manager (HKM) showed areas in the kitchen where he cleaned once a month. He stated he cleaned under the food preparation sink but he did not clean the area where there was residue build-up around the dairy refrigerator. He stated to get to the area where there was residue build-up around the dairy refrigerator, he would need to open the refrigerator door. However, he stated he did not open refrigerator doors and did not move big items such as refrigerators to clean under or around them. He stated he only cleaned under things that were easily moveable. He stated he only cleaned the floors and did not clean other areas in the kitchen such as tile baseboards or walls. d. An observation on 12/6/2021 at 9:36 a.m., showed knives were stored on the wall in a knife holder behind the food preparation sink. Directly above the knife holder was a bug extermination machine. The machine had a fly on the bottom of it. A cord from the machine was plugged into the wall and the cord went behind the knives stored in the knife holder. The cord had a plastic white cover around it. The plastic cover had fuzzy gray residue on the entire surface as well as white residue flaking off of the cover. This cover came into contact with the knife blades stored in the holder. The knives were pulled out of the holder and two knives had dried residue on the blades in addition to a white flaky substance. The holder for the knives also had a dried residue on the surface that resembled food residue. In an interview and concurrent observation of the knife storage area on 12/6/21 at 12:32 p.m., the DSS confirmed the knife storage holder and knives stored in the holder had to be cleaned. She also said the wall around the knife holder and the cord cover from the bug machine was not clean. e. During an observation on 12/6/2021 at 2:26 p.m., the rubber gaskets on the on two of the four doors of the beverage refrigerator had black grime build up in the grooves of the gasket. The grime wiped off with paper towel. In addition, the gaskets on the two lower doors were ripped and coming detached from the door. During an observation and concurrent interview with the DSS, on 12/6/2021 at 2:27 p.m., the DSS confirmed the observation that the gaskets in the beverage refrigerator had black grime imbedded in the grooves. She stated the gaskets were not on a cleaning schedule and stated, when they [kitchen staff] get a chance they will clean. She also confirmed the gaskets were ripped and said they needed to be replaced. f. During an observation and concurrent interview with the DSS, on 12/7/2021 at 10:30 a.m., the light switch located on the wall to the right at the entrance of the food storage room had silver tape attached. The tape was on the light switch cover and over the switch. The tape was peeling off and had a black residue on the surface. Also, the light switch cover had brown and black grime on the surface. The DSS confirmed the observation of black grime around the light switch cover and stated it was grease. g. During an observation and concurrent interview with Maintenance Supervisor D (MS D), on 12/6/2021 at 10:04 a.m., black residue was on the wall above the sink on the dirty side of the dish machine. The residue was mainly spread on the wall above a plastic strip that ran horizontally along the wall. The residue wiped off with a paper towel. MS D confirmed there was black residue. h. During an observation, on 12/7/2021 at 12:50 p.m., the entry to the kitchen had black grimy build up in the corners and along the edges near the baseboard and two tiles were broken and separated from the wall with grimy buildup between the wall and the backside of the baseboard tile. During an observation and concurrent interview with the DSS, on 12/7/2021 at 12:50 p.m., the DSS confirmed that two tiles in the entry to the kitchen along the baseboard were broken and separated from the wall. The DSS stated she did not notice them previously. i. During an observation on 12/6/2021 at 9:34 a.m., an industrial mounted counter can opener was attached to the food preparation table. One of the three screws that attached to the can opener holder to the table was missing. The missing screw hole had buildup of black grime and food particles. The can opener holder, where the shaft of the can opener was held when the can opener was being stored, was dented, and had a significant amount black and orange grime on the surface including the area that came into contact with the can opener shaft. The can opener shaft had orange residue on most of the surface. In addition, the cogwheel had a significant amount of orange residue in the grooves. The blade was worn so it was flat and not pointed and the coating was peeled off. In an interview on 12/6/21 at 12:32 p.m., the DSS confirmed the can opener was rusty and had residue on the surface, was missing a screw in the base, and appeared to have food particles and grime on it and the base. j. During an observation and concurrent interview with the DSS and MS D, on 12/6/2021 at 10:14 a.m., the standing mixer had a metal bowl with orange and black residue on the inside surface of the bowl. MS D stated the residue inside the mixer bowl was rust and the mixer should be taken out of the kitchen. The DSS confirmed there was orange build up in the mixing bowl. She stated .it is rusted .and could contaminate food. k. During an observation on 12/6/2021 at 2:26 p.m., the four-door beverage refrigerator located next to the stove, had wire racks for shelving. There was orange build-up covering the entire surface of the racks. During an observation and concurrent interview with the DSS, on 12/06/2021 2:21 p.m., she stated it looked like rust, in reference to the racks on the beverage refrigerator. l. During an observation and concurrent interview with the DSS, on 12/6/2021 at 9:42 a.m., cutting boards ready for kitchen staff use were observed stored on the food preparation counter near the food preparation sink. The red cutting board had orange spots on it. The white cutting board had black and blue spots on it. The DSS confirmed the cutting boards were stored ready for use and the two cutting boards were dirty. m. During an observation, on 12/6/2021 at 9:40 a.m., a metal strainer that covered the drain hole for the food preparation sink was covered in an orange residue. During an observation and concurrent interview with the DSS, on 12/6/2021 at 12:33 a.m., the DSS stated the drain strainer in the food preparation sink was rusted. n. During an observation and concurrent interview with MS D, on 12/6/2021 at 10:17 a.m., the food preparation sink drain was plumbed directly into the wall. No air gap was observed. MS D stated the food preparation sink was plumbed directly to the sewage drain and confirmed there was no air gap for this drain. During an observation on 12/7/2021 at 10:52 a.m., the ice machine drained water from a plastic pipe attached to the back of the machine. The drainpipe led to a drain in the floor that had a cylinder around it. The end of the drainpipe went into the cylinder. When water drained from the ice machine the cylinder around the drain filled and overflowed not allowing the water to flow out from the drainpipe without backing up, thus there was no air-gap for the ice machine drainpipe. During an observation and concurrent interview with MS E, on 12/07/2021 at 11:37 a.m., MS E confirmed there was no air gap for the ice machine. According to the 2017 Federal Food Code, there is to be an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment that is at least twice the diameter of the water supply inlet may not be less than 1 inch. o. An observation on 12/6/2021 at 9:27 a.m., indicated a plastic container of peanut butter had peanut butter on the rim and side of the container. The container felt greasy to the touch. The container was stored on shelving next to the oven ready for use. In an interview on 12/6/21 at 12:32 p.m., the DSS confirmed the peanut butter container had peanut butter on the outside surface and stated it was a concern but would be more of a concern if they had bugs. p. During an observation and concurrent interview with the DSS, on 12/6/2021 at 10:32 a.m., four boxes of long grain and wild rice blend were stored in the dry storeroom and ready for use. The dates on the boxes indicated the rice expired on 12/1/2021. The DSS confirmed the four boxes of rice were expired. During a record review of the facility's policy, titled Food Storage, dated 2017, showed all food items are to be dated upon receipt and used prior to expiration date.

Based on observation, interview and record review, the facility failed to ensure the proper upkeep, maintenance, and safe operating conditions of the kitchen appliances: 1. dairy reach-in refrigerator 2. multi-door reach-in freezer These failures had the potential to attract pests (cross-reference F-925) and impact the ability of the equipment to operate as intended leading to improper storage of food resulting in food that is not safe and/or poor quality for 90 residents who received food from the kitchen. Findings: 1. During an observation on 10/6/2021 at 9:48 a.m., the reach-in refrigerator that held dairy products, located next to the food preparation sink and the entry to the dry food storage, was observed to have a moist grime build up around the front of the refrigerator that would wipe off with paper towel. The DSS stated the grime was rust because the refrigerator leaked. During an observation and concurrent interview with the Dietary Services Supervisor (DSS), on 12/10/2021 at 9:54 a.m., the DSS stated the dairy refrigerator leaked .on and off since October 2021. She said water would accumulate on the floor in front of the refrigerator and once or twice a week staff would wipe up the water. Review of the facility's policy, Maintenance Service, revised December 2009, showed the maintenance department is responsible for maintaining the equipment in the facility in a safe and operable manner at all times, and will keep records of work order requests. According to the 2017 Federal Food Code, equipment is to be maintained in a state of good condition and repair to retain their characteristic qualities under normal use. 2. During observation of the the multi-door, reach-in freezer, on 12/6/2021 at 9:51 a.m., located next to the entrance of the dry storage and the coffee area, was observed to have a significant amount of ice chunks hanging from the top of the freezer ceiling and scattered on the freezer floor. This freezer held a variety of frozen foods such as meat, ice cream, and waffles. During observation, on 12/07/21 at 10:40 a.m., the ice cream cups and waffles were observed to be soft to the touch and not frozen solid. Review of the invoice dated 12/7/21, showed a technician serviced the reach-in freezer and stated the ice-build up was due to the freezer being too full with boxes stacked to the top and not allowing good air circulation During record review of the facility's policy, Maintenance Service, revised December 2009, indicated the maintenance department is responsible for maintaining the equipment in the facility in a safe and operable manner, will develop and maintain a schedule of maintenance, and will maintain receipts of the inspections and maintenance. According to the 2017 Federal Food Code, stored frozen foods are to be maintained frozen. Also, equipment is to be maintained in a state of good condition and repair to retain their characteristic qualities under normal use.

Based on observation, interview, and record review the facility failed to provide an effective pest control program to ensure a pest free environment when the facility had flying black bugs in the kitchen. This failure had the potential to cross-contaminate food and utensils leading to illness for 90 residents who received food from the kitchen. Findings During observation on 12/6/2021 at 9:39 a.m., a small black fly was observed on the underside of the bug extermination machine, which was mounted above the clean, ready for use, knives. During an observation and concurrent interview on 12/6/2021 at 9:45 a.m., with the Dietary Services Supervisor (DSS), she showed a reach-in refrigerator holding dairy products had a significant amount of thick residue at the base of the front, near the floor. The thick residue was orange, brown, and black in color. It was sticky and moist and was removable with a paper towel. The DSS stated it was rust because the refrigerator was leaky. During observation on 12/7/2021 at 10:08 a.m., five small flies were observed on water pitchers. During observation on 12/7/2021 at 10:09 a.m., three small flies were observed on the wall above the dishwashing machine. They also landed on dirty dishes with half eaten food returned from the resident lunch meal. During observation and concurrent interview with the Dietary Services Supervisor (DSS), on 12/7/2021 at 10:04 a.m., she confirmed the observation of black flies in the kitchen and stated they are a concern. During observation and concurrent interview with the Dietary Services Supervisor (DSS) on 12/10/2021 at 9:54 a.m., she confirmed the observation of black, orange, and brown build up around the dairy refrigerator. The DSS stated the dairy refrigerator has leaked .on and off since October 2021 and once or twice a week staff would clean up around the dairy refrigerator. During a telephone interview with a local exterminator the facility used for pest and rodent management, on 12/9/2021 at 9:23 a.m., the Pest Technician (PT 1) stated he was at the facility on 12/1/2021 for a routine service when he was notified of flies in the kitchen. He thought the flies were likely phorid flies and stated he saw about 10 flies on 12/7/2021 when he treated the kitchen for flies. He stated he thought the flies were breeding under the dairy refrigerator and stated the dairy refrigerator sits directly on the floor, it was damp under it, and .had a lot of gook under it. PT 1 stated under the refrigerator there was a mixture of what he thought was rust and food particles and that decomposing wet organic matter is the perfect breeding area for the flies in the kitchen. Review of the facility's policy, Pest Control, revised May 2008, indicated the facility shall maintain an effective pest control program and be kept free of insects. Review of the facility's policy, Sanitization, dated October 2008, indicated surfaces not in contact with food should be cleaned regularly on a schedule to prevent the accumulation of grime. During record review of the facility's policy, Sanitization, revised October 2008, indicated all areas of the kitchen should be kept clean. According to the 2017 Federal Food Code, equipment that is not easily movable shall have access for cleaning along sides, behind, and under equipment. Floor mounted equipment is to be sealed to the floor or elevated on legs that to allow for cleaning.

Based on observation, interview, and record review the facility failed to treat one of 18 sampled residents (Resident 14) with dignity and respect when the certified nursing assistant (CNA) repeatedly wiped liquid from Resident 14's face with the edge of a cup while assisting her to eat lunch. This failure had the potential to cause emotional distress to the resident. Findings: A review of Resident 14's clinical record indicated a diagnosis of Alzheimer's disease (a disease of the brain that causes problems with memory, thinking and behavior). A review of the Minimum Data Set (MDS, an assessment tool) indicated Resident 14 required extensive assistance with eating. During a dining room observation on 5/13/19 at 12:52 p.m., CNA C sat next to Resident 14, tipped a cup into Resident 14's mouth, removed the cup and wiped the right side of Resident 14's mouth and cheek with the edge of the cup. CNA C then wiped Resident 14's mouth with a napkin. CNA C next tipped a cup into Resident 14's mouth, removed the cup, wiped the right side of Resident 14's mouth and cheek with the edge of the cup and then wiped Resident 14's mouth with a napkin. CNA C next tipped a glass of milk into Resident 14's mouth, removed the cup of milk, wiped the right side of Resident 14's mouth and cheek with the edge of the glass of milk and then wiped Resident 14's mouth with a napkin. CNA C next tipped a cup into Resident 14's mouth, removed the cup and wiped the right side of Resident 14's mouth and cheek with the edge of the cup. CNA C then wiped Resident 14's mouth with a napkin. During a phone interview with CNA C on 5/14/19 at 11:07 a.m., she stated she remembered feeding Resident 14 with a cup and then wiping Resident 14's face with the edge of the cup during lunch on 5/13/19. CNA C stated she didn't think she was supposed to wipe a resident's face with the edge of a cup. During an interview with the director of nursing (DON) on 5/14/19 at 11:22 a.m., she stated the CNA should not be wiping the side of a resident's face with a cup. A review of the facility's policy, Assistance With Meals dated 2017, indicated residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.

4. Review of Resident 33's clinical record indicated the facility transferred the resident to the acute care hospital on 4/6/19. There was no documentation in the record indicating the facility notified the ombudsman of this transfer. During an interview with the SSD on 5/15/19 at 10:28 a.m., he stated he was just new at the facility and had to look at facility policy for notifying the ombudsman. During an interview with the DON on 5/16/19 at 1:20 p.m., she stated she cannot give information regarding when the ombudsman should be notified. 3. Review of Resident 85's clinical record indicated the facility transferred him to the acute care hospital on 2/6/19. There was no documentation in the record indicating the facility notified the ombudsman of this transfer. During an interview with the social service director (SSD) on 5/16/19 at 10:27 a.m., he stated the SSD was responsible for notifying the ombudsman about resident hospitalizations. He stated there was no documentation to indicate that the ombudsman was notified of the hospital transfer of Resident 85 on 2/6/19. He confirmed the ombudsman should be notified in writing when residents were transferred to the hospital. Based on interview and record review, the facility failed to notify the State Long-Term Ombudsman (LTO, a person whose role is to advocate for, to address concerns and to advise long-term residents of their rights) of an emergent transfer from the facility to acute care hospital, for four of four sampled residents (Residents 33, 43, 45, and 85). This failure had the potential to violate the residents' rights to an advocate regarding their transfer from the facility. Findings: 1. Review of Resident 43's clinical record indicated he was transferred to the acute care hospital via emergency transport on 4/3/29 and returned to the long term care facility on 4/5/19. A review of Resident 43's Bedhold Informed Consent Notification indicated a family member was notified by phone of Resident 43's transfer to the acute care hospital on 4/2/29. During an interview with the regional clinical resource (RCR) on 5/5/19 at 11:27 a.m., she provided a copy of Resident 43's Bedhold Informed Consent Notification but stated she was unable to find Resident 43's Notice of Transfer/Discharge or evidence the LTO was sent a copy of the notice. 2. Review of Resident 45's clinical record indicated he was transferred to the acute care hospital on 4/12/19 and returned to the long term care facility on 4/15/19. A review of Resident 45's Bedhold Informed Consent Notification indicated Resident 45 signed the above bed hold consent form and transferred to the acute care hospital on 4/12/19. During an interview with the director of nursing (DON) on 5/16/17 at 12:00 p.m., she provided a copy of Resident 45's Bedhold Informed Consent Notification but stated she was unable to find Resident 45's Notice of Transfer/Discharge or evidence the LTO was sent a copy of the notice. A review of the facility's policy, Transfer or Discharge Notice, indicated Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: . an immediate transfer or discharge is required by the resident's urgent medical needs . a copy of the notice will be sent to the Office of the State Long-Term Ombudsman.

Based on observation, interview, and record review, the facility failed to timely replace one of three refrigerated emergency kits (e-kit, a box containing medication needed for immediate administration) from the provider pharmacy and failed to complete documentation on the emergency medication log. These failures could result in unavailability of medications during emergency situations and inaccurate accountability of medications. Findings: During an inspection of Station 2's medication room with the director of staff development (DSD) on 5/13/19 at 1:46 p.m., an e-kit was removed from the refrigerator and noted to be sealed with two yellow tabs (a zip tie used to secure the e-kit). The DSD stated yellow tabs mean the e-kit has been opened. The DSD confirmed there was no requisition or paperwork inside the e-kit to indicate when the e-kit was opened or what contents were removed. During an interview with licensed vocational nurse D (LVN D) on 5/13/19 at 3:15 p.m., she stated when an e-kit is opened and contents are used, a form is completed and placed in the e-kit indicating what medication was used and for which resident. She stated the e-kit is sent to the pharmacy right away to be restocked. During an interview with the director of nursing (DON) on 5/14/19 at 10:00 a.m., she stated the staff should fax the pharmacy when they open an e-Kit to request a replacement. She produced a document titled Emergency Kit Pharmacy Log that indicated Humalog insulin (insulin, a medication that lowers blood sugar) and Regular insulin were removed from the Station 2 e-kit on 4/13/19. Instructions listed on the document indicated to fill out all appropriate areas in log and return yellow copy to pharmacy in the emergency kit. The DON confirmed the log entry was incomplete and did not identify resident's name, directions, time ordered or time given, physician, quantity, or printed nurse's name on the document. She acknowledged the e-kit was opened on 4/13/19 and had not been replaced. Review of the facility's policy, Medication Ordering and Receiving from Pharmacy dated 8/2014, indicated When an emergency or stat dose of a medication is needed, the nurse unlocks the container .completes the emergency e-kit slip and reseals the emergency supply . the used sealed kits are replaced with the new sealed kits within 72 hours of opening. A record of the name, dose of the drug administered, name of the patient, date, time of administration, and the signature of the person administering the dose shall be recorded in the emergency log book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the pharmacy consultant (PC) failed to identify irregularities for one of five residents (46) when Resident 46 hemoglobin a1c (hgb a1c, a test used to detect diabetes and measures the average blood sugar level for the past two to three months) was not identified. This failure had the potential to result in adverse consequences related to the medication and affect the residents' functional status. Findings: Review of Resident 46's clinical record indicated he was re-admitted to the facility on [DATE] with the diagnoses including dementia (memory loss) type 2 diabetes (high blood sugar level) and psychotic disorder (severe mental disorder that cause abnormal thinking and perceptions). Review of Resident 46's physician's order dated [DATE], indicated Seroquel (an antipsychotic medication used to treat mental or mood conditions) give 2.5 milligrams (mg, unit of measurement) by mouth at bedtime for psychotic disorder as manifested by striking out towards others and delusional thoughts. Further review of Resident 46's physician order did not indicate blood sugar monitoring. During an interview with the regional clinical resource (RCR) and the director of nursing (DON) on [DATE] at 1:25 p.m., the RCR and the DON stated the facility does not have a protocol for laboratory testing (lab test) for the use of Seroquel. During a telephone interview with the PC on [DATE] at 1:46 p.m., he stated lab test for Seroquel depends on the code status of the resident if they were DNR (do not resuscitate, no cardiopulmonary resuscitation (CPR) required) comfort care or full code (requires CPR). The PC further stated he could recommend hgb a1c possibly every six months for residents who were on Seroquel with history of diabetes. Review of Resident 46's random comprehensive metabolic panel (CMP, a blood test that provides information to kidney and liver function, sugar and protein levels and the electrolyte and fluid balance in the body) dated [DATE], indicated random glucose result was high. According to lexicomp online (a widely used website for clinical practice and drug information resources) Atypical antipsychotics have been associated with development of hyperglycemia .Patients with risk factors for diabetes (e.g., obesity or family history) should have a baseline fasting blood sugar and periodically during treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored and labeled appropriately when inspections of two medication rooms and a central supply room found: 1. Medication room [ROOM NUMBER] with an expired tube containing Lubrifresh eye ointment; 2. Medication room [ROOM NUMBER] with two opened multi-dose vials (contains more than one dose of medication) of Tuberculin Purified Protein Derivative solution (PPD - used for tuberculosis screening); One vial had a sticker dated [DATE] and the other vial was undated; and 3. Central Supply Storage Room with four bottles of expired enteral formula (liquid nutrition provided through a tube placed in the nose, the stomach, or the small intestine). These failures had the potential for residents to receive expired, contaminated, or deteriorated medications and biologicals. Findings: 1. During a medication room inspection on [DATE] at 1:46 p.m., with director of staff development (DSD), a tube of Lubrifresh eye ointment was found in the House Supply cabinet in medication storage room [ROOM NUMBER] located at Station Three. The Lubrifresh eye ointment expired on 4/2019. The DSD confirmed the ointment was expired and should be removed and not stored with the House Supply medications. Review of the facility's policy, Disposal of Medications dated 10/2017, indicated When medications are expired, discontinued by a prescriber, a resident is transferred, or discharged . the medications are marked as discontinued or stored in a separate location and later destroyed. 2. During a medication room inspection on [DATE] at 3:02 p.m., with the DSD, two opened multi-dose vials of PPD solution marked House supply were observed in the refrigerator in the medication storage room [ROOM NUMBER] located at Station Two. One vial had a sticker with a date of [DATE] and the second vial was undated. During a concurrent interview with the DSD, she confirmed the one vial was undated and the other vial had a sticker dated [DATE]. She stated medications should be labeled when opened but stated she could not verify what the date indicated on the dated vial. She further stated she did not know the facility policy regarding the expiration of PPD solutions once opened. Review of Lexicomp online (www.[NAME]-comp.com, a nationally recognized drug information resource) indicated the vial of tuberculin PPD which has been entered and in use for 30 days should be discarded because oxidation (the combination of a substance with oxygen) and degradation (decline to a lower condition) may have reduced the potency (a measure of the activity of a drug in a biological system). 3. During an inspection of the central supply storage room on [DATE] at 2:27 p.m., with licensed vocational nurse E (LVN E), four 1 liter bottles of Jevity 1.5 cal enteral formula were observed with expiration dates of [DATE]. LVN E confirmed the expiration dates on all 4 bottles and stated the bottles should be removed and discarded from the supply room when expired. Review of the facility's policy, Enteral Feedings - Safety Precautions revised 11/2018, indicated to Maintain strict adherence to storage conditions and time frames . maintain inventory controls and discard any formula past the expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure proper infection control practices were followed when: 1. for Resident 283, the licensed nurse did not properly perform hand hygiene during a dressing change; and 2. certified nursing assistant C (CNA C) did not perform hand hygiene in between assisting residents. These failures had the potential to spread infection in the facility. Findings: 1. Review of Resident 283's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including acute pyelonephritis (a sudden and severe kidney infection). During a dressing change observation for Resident 283 on 5/16/19 at 8:17 a.m., licensed vocational nurse A (LVN A) washed her hands, put on gloves, and touched the bed controller with both gloved hands. LVN A did not change gloves and wash hands before she removed a urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) dressing. During an interview with LVN A on 5/16/19 at 8:39 a.m., she confirmed the above observation and stated she should remove gloves, wash hands and put on new gloves before changing the dressing. During an interview with the director of staff development (DSD) on 5/16/19 at 9:16 a.m., she stated the staff should perform hand hygiene before a dressing change. Review of the facility's policy, Handwashing/Hand Hygiene revised August 2015, indicated Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . Before handling clean or soiled dressing . 2. During a dining observation on 5/13/19 at 1:02 p.m., CNA C was feeding Resident 14, CNA C proceeded to help feed Resident 2 without performing hand hygiene. During a telephone interview with CNA C on 5/14/19 at 11:10 a.m., she confirmed the above observation. CNA C stated she was supposed to perform hand hygiene in between helping Resident 2 and Resident 14. During an interview with the director of nursing (DON) on 5/15/19 at 3:34 p.m., the DON stated staff should perform hand hygiene when feeding two residents at the same time. Review of the facility's policy, Handwashing/Hand Hygiene revised August 2015, indicated Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before and after assisting a resident with meals.

Based on observation, interview, and facility document review, the facility failed to follow proper sanitation and food handling practices when: 1. Proper procedures were not followed to thaw meat; 2. Kitchen staff did not demonstrate the proper procedures for testing chlorine (chemical) sanitizer used for dishwashing; and 3. Kitchen staff did not demonstrate the proper procedures for testing the strength of sanitizer used for sanitizing food contact surfaces. These failures had the potential to cause food-borne illness. Findings: During a kitchen observation on 5/13/19 at 10:45 a.m., two 10 pound packages of chicken thighs were observed in a container located in a food preparation sink. Water was trickling (to flow or fall by drops, or in a small, gentle stream) into the container and was coming into contact with only a portion of one of the ten pound bags. The second 10 pound bag was not in contact with any running water. Neither of the ten pound bags were submerged in the water. In a concurrent interview with the Dietary Supervisor (DS), she stated the chicken was being thawed and would be served for dinner. She acknowledged the trickle of water was only in contact with one of the bags of chicken and confirmed all thawing chicken should be in contact with the running water. She acknowledged the two ten pound bags were not submerged in the water and confirmed they should be submerged. The Federal Food Code 2017 (Food codes - the standard of practice for food service operations) 3-501.13: Thawing, indicated TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed . Completely submerged under running water with sufficient water velocity to agitate and float off loose particles in an overflow . During a kitchen observation on 5/13/19 at 8:27 a.m., in the presence of the registered dietician (RD) and DS, dietary aide F (DA F) demonstrated how to test chlorine sanitizer in the dishwashing machine. He dipped the test strip (test paper that measures the concentration of the sanitizer in the solution) for 4 seconds then began waving it around in the air and stated I let it air dry and wait one minute before I read it. After 6 seconds he compared the color of the test strip against the color standards on the test strip container. When asked how long he left the strip in the solution, DA F responded one minute. During a kitchen observation on 5/13/19 at 2:35 p.m., in the presence of the RD and DS, dietary aide H (DA H) demonstrated how to test chlorine sanitizer in the dishwashing machine. She dipped the test strip for 5 seconds. She immediately compared the color of the test strip against the color standards on the test strip container. When asked how long she left the strip in the solution, DA H responded 5 seconds. During a kitchen observation on 5/4/19 at 9:51 a.m., in the presence of the RD and DS, dietary aide I (DA I) demonstrated how to test chlorine sanitizer in the dishwashing machine. She dipped the test strip for 5 second. She immediately compared the color of the test strip against the color standards on the test strip container. When asked how long she left the strip in the solution, DA I responded one second. Review of the Ecolab chlorine test paper instructions indicated to dip and remove quickly, blot immediately with paper towel, and compare to the color chart at once. During a kitchen observation 5/13/19 at 10:55 a.m., in the presence of the RD and DS, dietary aide G (DA G) demonstrated how to test the strength of the quaternary ammonium solution (QUAT, used to sanitize food contact surface areas). He dipped the QUAT test strip in the QUAT solution for two seconds then he immediately compared the color of the test strip against the color standards on the test strip container. When asked how long he left the strip in the solution, DA G responded two seconds. During a kitchen observation 5/13/19 at 2:35 p.m., in the presence of the RD and DS, dietary aide H (DA H) demonstrated how to test the strength of the QUAT solution. She dipped the QUAT test strip in the QUAT solution for 7 seconds then compared the color of the test strip against the color standards on the test strip container after 5 seconds. When asked how long she left the strip in the solution, DA H responded I dip it for 5 seconds then wait 5 seconds for it to change to the right color. During a kitchen observation 5/14/19 at 9:51 a.m., in the presence of the RD and DS, dietary aide I (DA I) demonstrated how to test the strength of the QUAT solution. She dipped the QUAT test strip in the QUAT solution for 4 seconds then she immediately compared the color of the test strip against the color standards on the test strip container. When asked how long she left the strip in the solution, DA I responded two seconds. Review of the Ecolab Oaisis 146 Multiquat sanitizer test paper instructions indicated to dip test paper for 10 seconds, don't shake, and compare the colors immediately with colors on the test paper package. During an interview on 5/14/19 at 9:52 a.m., with the DS, she stated when testing the strength of the QUAT solution the test strip needs to be immersed for 20 seconds in the sanitizing solution prior to removing it and reading it. During an interview on 5/16/19 at 9:15 a.m., with registered dietician (RD) she stated the staff was not testing the chlorine sanitizer or quatinary sanitizing solutions properly according to manufacturer's recommendations. She stated she had provided an inservice to all kitchen staff on 5/13/19 when she observed improper testing techniques conducted on chlorine and Quat sanitizer solutions by the kitchen staff.